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Property of the 

Lancaster City and County 
Medical Society 



No. 



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THE 



AMERICAN JOURNAL 



OF THE 



MEDICAL SCIENCES. 



EDITED BY 



ISAAC HAYS, M.D., 

SURGEON TO WILLS HOSPITAL, 

FELLOW OF THE PHILADKLPHIA COLLEGE OF PHYSICIANS; MEMBER OF THE 

AMEBICAN MEDICAL ASSOCIATION," OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THl 

ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA, 

&C. &C. &C. 



NEW SERIES, 
VOL. XIX, 




PHILADELPHIA: 
LEA & BLANCHARD. 

LONDON: 
JOHN WILEY/ AND JOHN MILLEK, 



1850. 



69445 



Enteked according to Act of Congress, in the year 1850, by 

LEA AND BLANCHARD, 

m the Clerk's Office of the District Court of the Eastern District of Pennsylvania. 







PHILADELPHIA : 
T. K. AND P. G. COLLINS, PRINTERS. 



y,V9 
Med. 



TO BEADEES AND CORRESPONDENTS, 

Communications have been received from Drs. W. L. Atlee, C. J. Clark, 
John Farrell, C. V. Bemis, J. St. J. Guerard, John H. Griefin, and Richard 
Mc Sherry. 

The following works have been received :— 

Medico-Chirurgical Transactions. Published by the Royal Medical and 
Chirurgical Society of London, Vol. XXXII. London, 1849. (From the 
Society.) 

The History of the Cholera in Exeter in 1832. By Thomas Shapter, M. D., 
Physician to the Devon and Exeter Hospital, &c. &c. London, 1849. (From 
the Author.) 

The Diseases of Infants and Children. By Fleetwood Churchill, M. D., 
M. E. I. A. Philadelphia, Lea & Blanchard, 1850. (From the Author.) 

Medical Ethics ; or a Code of Institutes and Precepts adapted to the Profes- 
sional Conduct of Physicians and Surgeons. By the late Thomas Percival, 
M. D., F. R. S. Third edition. Oxford, 1849. (From the Editor.) 

Code of Ethics of the American Medical Association. (Reprinted from the 
American edition.) Oxford, 1849. (From the Editor.) 

Remarks on the Causes and Morbid Anatomy of Mental Diseases. By John 
Webster, M. D., F.R. S., &c. Reprinted from the Medico-Chirurgical Transac- 
tions, Vol. XXXII. (From the Author.) 

On the Health of London during the six months terminating 20th Sept. 1849, 
more especially in reference to Cholera. By John AVebster, M. D., &c. &c. 
Reprinted from the London Journal of Medicine. (From the Author.) 

A Treatise on Diseases of the Bones. By Edward Stanley, F. R. S., Presi- 
sident of the Royal College of Surgeons of England, and Surgeon to St. Bar- 
tholomew's Hospital. Philadelphia, Lea & Blanchard, 1849. (From the Pub- 
lishers.) 

The three kinds of Cod-liver Oil ; comparatively considered, with reference 
to their Chemical and Therapeutic Properties. By L. J. de Jongh, M. D., of 
the Hague. Translated from the German, with an Appendix, and Cases. By 
Edward Carey, M. D. To which is added an Article on the Subject from Dun- 
glison on New Remedies. Philadelphia, Lea & Blanchard, 1849. (From the 
Publishers.) 

A Treatise on the Diseases and Special Hygiene of Females. By Colombat 
DE L'IsERE. Translated from the French, with Additions. By Charles D. 
Meigs, M. D., &c. &c. A new edition, revised, with woodcut illustrations. 
Philadelphia, Lea & Blanchard, 1850. (From the Publishers.) 

Principles of Human Physiology. With their chief applications to Pathology, 
Hygiene, and Forensic Medicine. By Wm. B. Carpenter, M. D., F.R. S., &c. 
&c. Fourth American edition, with extensive additions and improvements by 
the Author, with 2 plates, and 304 woodcuts. Philadelphia ,Lea & Blanchard, 
1850. (From the Publishers.) 

Surgical Anatomy. By Joseph Maclise, Surgeon, with Coloured Plates. 
Philadelphia, Lea & Blanchard, 1850. Part I. (From the Publishers.) 

A Practical Treatise on the Diseases of Children. By D. Francis Condie, 
M. D., Secretary of the College of Physicians, &c. &c. &c. Third edition, re- 
vised and augmented. Philadelphia, Lea & Blanchard, 1850. (From the Pub- 
lishers.) 

On the Diseases of Infants and Children. By Fleetwood Churchill , M. D., 
M. R. I. A., &c. Philadelphia, Lea & Blanchard, 1850. (From the Pub- 
lishers.) 



4 TO READERS AND CORRESPONDENTS. 

Curability de la Phthisie et des Scrofules appuyee sur des preuves authen- 
tiques. Par A. M. Bureaud-Riofrey, D. M. P., &c. &c. &c. Paris, 1847. 
(From the Author.) 

Du cholera : moyens preservatifs et curatifs ; ou, philosophic des grandes epi- 
d6mies. Par A. M. Bureaud-Riofrey, M. D. P., &c. &c. Paris, 1847. (From 
the Author.) 

Recherches Statistiques sur la nature et les causes des Maladies oculaires ob- 
serv^es en Belgique, et en particulier dans la province du Brabant. Rapport 
adresse a M. Liedts, Gouverneur du Brabant, &c. &c. Par Le Docteur Flo- 
rent CuNiER, Chirurgien de Tlnstitut Ophthalmique de Bruxelle, &c. &c. &c. 
Bruxelles, 1847. (From the Author.) 

M^moire sur I'ophthalmie contagieuse qui rfegne dans la classe pauvre et 
ouvri^re. Par Le Docteur Florent Cunier. Bruxelles, 1849. (From the 
Author.) 

Notizen fiir praktische Arzte uber die neusten beobachtungen in der Medicin, 
mit besonderer beriicksichtigung der krankheits — behandlung zusammengestellt 
von Dr. F. Graevell, arzt in Berlin. Berlin, 1848. (From Dr. Oppenheim.) 

Verhaltniss des organischen zum Anorganischen, oder Grundlinien, der verg- 
leichenden Physiologic und Physik. Von M. C. Wolfring, D. M. P. Erlangen, 
1848. (From Dr. Oppenheim.) 

Ueber die ausseren Standes-Verhaltnisse der Militair-aerzte insbesondere in 
Bayern. Von Dr. F. Sommer. Erlangen, 1848. (From Dr. Oppenheim.) 

Brunnenarztliche Mittheilungen uber die whal der Jahreszeit beim gebrauche 
der karlsbader mineralquellen, mit besonderer bezugnahme auf fruhlingskuren. 
Von Leopold Fleckles, M. D. Leipsig, 1848. (From Dr. Oppenheim.) 

Dr. Joseph Carl, Ed. Hoser's Riickbliche auf sein Leben und Wirken. Nach 
dessen Tode herausgegeben. Von Dr. W. R. Weitenweber, prakt. Arzte in 
Prag. &c. Prag. 1848. (From Dr. Oppenheim.) 

Verslag over de Clinick voor inwendige ziekten, gegeven bij de clinische 
school te Rotterdam. Door G. Ph. F. Groshans, M. D. Rotterdam, 1848. 

A Magyarhonban Mostan^ban uralkodi Burgonyabetegseg eszserii mezei 
gazd^k 6s term^szetvizsgdlok sz4m4ra. Irta Tognio Lajos. Presten, 1847. 

Observations on the Spread of Asiatic Cholera, and its communicable nature. 
By John Evans, M. D., Professor of Obstetrics and Diseases of Women and 
Children in Rush Medical College. Chicago, 1849. (From the Author.) 

A Conspectus of the Pharmacopoeias of the London, Edinburgh, and Dublin 
Colleges of Physicians, and of the United States Pharmacopoeia: being a 
Practical Compendium of Materia Medica and Pharmacy. By Anthony Todd 
Thomson, M. D., F.L. S., &c. The fifth American edition, much enlarged and 
improved. Edited by Charles A. Lee, M. D., &c. From the thirteenth Eng- 
lish edition. New York: Samuel S. and William Wood, 1849. (From the 
Publishers.) 

Statistics of Cholera : with the Sanitary Measures adopted by the Board of 
Health prior to, and during the prevalence of, the Epidemic Cholera in Phila- 
delphia in the Summer of 1849, chronologically arranged. Prepared by the 
Sanitary Committee appointed by the Board, and ordered for publication, Oct. 
10th, 1849. Philadelphia, 1849. (From Dr. W. Jewell.) 

Report of the Proceedings of the Cholera Committee of the Board of Health, 
in relation to the Cholera, as it prevailed in New York in 1849. New York, 
1849. 

The Practice of Surgery : embracing Minor Surgery, and the Application of 
Dressings, &c. &c. &c. By John Hastings, M. D., U, S. N., with numerous 
illustrations. Philadelphia, Lindsay & Blakiston, 1850. (From the Publishers.) 

Inflammation: its Symptoms, Causes, and Treatment, philosophically con- 
sidered. By J. P. Batchelder, M. D. New York, 1848. 

A list of the Medicinal Plants of Ohio (not embraced in Wood and Bache's 



TO READERS AND CORRESPONDENTS. 

TJ. S. Dispensatory), containing, as far as known, a brief account of their proper- 
ties. By John M. Bigelow, M.D. Columbus, 1849. (From the Author.) 

Contributions to Physiology. By Bennet Dowler, M. D. New Orleans, 1849. 
(From the Author.) 

Address on Free Medical Schools, introductory to the Session of 1849-50, in 
Eush Medical College. By N. S. Davis, M. D., Prof. Phys. and Path. Chicago, 
1849. (From the Author'.) 

On the Propagation of Communicable Diseases. An Introductory Lecture 
to the Course of 1849-50, in the Medical Institute of Yale College. By J. 
Knight, M. D., Prof, of Surgery. New Haven, 1849. (From the Author.) 

Thirteenth Annual Report of the Trustees and Superintendents of the Ver- 
mont Asylum for the Insane. Sept. 1849. Montpelier, 1849. 

College of Physicians and Surgeons of the Upper Mississippi (Reorganiza- 
tion of Rock Island Medical School), second Session, 1849-50. Chicago, 1849. 
(From the Faculty.) 

Transactions of the American Medical Association. Instituted 1847. Vol. II. 

The following Journals have been received in exchange : — 

Revue Medico-Chirurgicale de Paris. Sous la Direction de M. Malgaigne. 
Sept., Oct., 1849. 

Zeitschrift fiir die gesammte Medicine, mit besonderer Riicksicht auf Hos- 
pital pranes und austandische Literatur. Herausgegeben von F. W. Oppen- 
HEiM, Oct., Nov., Dec, 1848 — Jan., Feb., March, April, May, June, Aug., Sept., 
1849. 

Adolph Henke's Zeitschrift fiir die Staatsarzneikunde, fortgetzt von Dr. A. 
SiEBERT. Erlangen, 1848. Heft. 3 & 4. 

Provincial Medical and Surgical Journal. Joint editors W. II. Ranking, 
M.D., and J. H. Walsh, Esq. Sept., Oct., Nov., 1849. 

The Retrospect of Medicine : being a Half-Yearly Journal, containing a Re- 
trospective View of every Discovery and Practical Improvement in the Medical 
Sciences. Edited by W. Braithwaite, Lecturer on Obstetrics, &c. &c. Jan., 
June, 1849. 

The Edinburgh Medical and Surgical Journal. Oct., 1849. 

The British and Foreign Medico-Chirurgical Review. Oct., 1849. 

The London Journal of Medicine, a Monthly Record of the Medical Sciences. 
Oct., Nov., 1849. 

London Medical Gazette. Sept., Oct., Nov., 1849. 

Monthly Journal and Retrospect of the Medical Sciences. London Editor 
Geo. E. Day, F.R.C.P. Edinburgh Editors A. Fleming, M. D., W. T. Gaird- 
NER, M. D. Oct., Nov. 

The Journal of Psychological Medicine, Mental Pathology. Edited by 
Forbes Winslow, M. D. Oct., 1849. 

Guy's Hospital Reports. Second Series, Vol. VI., Part II. Oct., 1849. 
Edited by Geo. Hilaro Barlow, M. A., and M. D. Cantab., Edward Coote, 
F.R.C.S., E. L. Birkett, M. D. Cantab., and Alfred Poland, F.R.C.S. 

The Dublin Quarterly Journal of Medical Science. Nov., 1849. 

Medical Times. Sept., Oct., Nov., 1849. 

Dublin Medical Press. Oct., Nov., 1849. 

The British American Journal of Medical and Physical Science. Edited by 
Archibald Hall, M.D. Sept., Oct., Nov., Dec, 1849. 

The American Journal of Insanity. Edited by the Officers of the New York 
State Lunatic Asylum, Utica. Oct., 1849. 

The New Jersey Medical Reporter, and Transactions of the New Jersey 
Medical Society. Edited by Joseph Parrish, M. D. Oct., 1849. 

1* 



6 TO READERS AND CORRESPONDENTS. 

The New York Journal of Medicine and the Collateral Sciences. Edited by 
S.S. Purple, M.D. Nov. 1849. 

The American Journal of Science and Arts. Conducted by Profs. B. Silli- 
MAN, and B. Silliman, Jr., and James D. Dana. Nov., 1849. 

The Ohio Medical and Surgical Journal. Edited by John Butterfield, 
M.D. Nov., 1849. 

The Charleston Medical Journal and Review. Edited by P. C. Gaillard, 
M. D., and W. De Saussure, M. D. Nov., Dec, 1849. 

The New Orleans Medical and Surgical Journal. Edited by A. Hester, 
M. D. Nov., 1849. 

The American Journal of Dental Science. Editors Chapin A. Harris, M. D., 
Amos Westcott, M. D., and Wm. H. Devinelle, M. D. Oct., 1849. 

The American Journal of Pharmacy, published by Authority of the Phila- 
delphia College of Pharmacy. Edited by Joseph Carson, M. D., Prof. Mat. 
Med., and Wm. Procter, Jr., Prof. Pharmacy. Oct., 1849. 

The Boston Medical and Surgical Journal. Edited by J. Y. C. Smith, M. D., 
Oct., Nov., Dec, 1849. 

Buffalo Medical Journal, and Monthly Review of Medical and Surgical 
Science. Edited by Austin Flint, M. D. Oct., Nov., Dec, 1849. 

Southern Medical and Surgical Journal. Edited by Paul F. Eve, M. D. 
Oct., Nov., Dec, 1849. 

The Medical Examiner, and Record of Medical Science. Edited by F. G, 
Smith, M. D., and Dr. H. Tucker, M. D. Oct., Nov., Dec, 1849. 

Transylvania Medical Journal. Edited by E. L. Dudley, M. D. Oct., 1849. 

The Western Journal of Medicine and Surgery. Edited by L. P. Yandell, 
M. D., and T. S. Bell, M. D. Oct., Nov., 1849. 

The Western Lancet. Oct., Nov., Dec, 1849. 

Communications intended for publication, and Books for Review, should be sent, /ree 
of expense, directed to Isaac Hats, M. D., Editor of the American Journal of the Medical 
Sciences, care of Messrs. Lea & Blanchard, Philadelphia. Parcels directed as above, and 
sent (carriage paid) under cover, to John Miller, Henrietta Street, Covent Garden, London ; 
or to John Wiley, or G. P. Putnam, New York; or W, D. Ticknor, Boston; or M. Hector 
Bossange, Lib, quai Voltaire, No. 11, Paris, will reach us safely and without delay. We 
particularly request the attention of our foreign correspondents to the above, as we are 
often subjected to unnecessary expense for postage and carriage. 

All remittances of money, and letters on the business of the Journal, should be addressed 
exclusively to the publishers, Messrs. Lea & Blanchard. 

0^ The advertisement-sheet belongs to the business department of the Journal, and 
all communications for it should be made to the publishers. 



CONTENTS 

OF THE 

AMEEICAN JOURNAL 

OF THE 

MEDICAL SCIENCES. 

NO. XXXYII. NEW SEMES. 
JANUARY, 1850. 



ORiaiNAL COMMUNICATIONS. 
MEMOIRS AND CASES. 

ART. PAGE 

I. Observations on the Prevention of Phthisis, and its proper Treatment 
in the Early Stage, with Cases illustrating its Natural History. By Ed- 
ward Hallowell, M. D., Fellow of the College of Physicians of Philadel- 
phia ; Member of the Academy of Natural Sciences, &c. - - 13 

II. On Angina Pectoris. By Samuel Kneeland, Jr., M. D., Boston, Massa- 
chusetts. - - - - - - - - -43 

III. On Hemorrhage from the Umbilicus, in New-Born Children ; with 
Cases. By Henry I. Bowditch, one of the Physicians of Massachusetts 
General Hospital. (Read before the Boston Society for Observation in 
Medicine and the Collateral Sciences, July 2d, 1849.) - - - 63 

IV. Extracts from the Records of the Boston Society for Medical Improve- 
ment. By Samuel Parkman, M. P., Secretary. - - - - 71 

V. Observations on the Occipital and Superior Maxillary Bones of the 
African Cranium. By John Neill, M. P., Demonstrator of Anatomy in 
the University of Pennsylvania. [With six woodcuts.] - - - 78 

VI. Notice of the Anatomical Phenomena in a Case of Ligature of the 
Subclavian Artery, four years subsequent to the Operation. By F. S. 
Ainsworth, M. D., Demonstrator of Anatomy, Mass. Med. College. 
(Communicated to the Boston Society for Medical Improvement.) - 83 

VII. Abscess in the Substance of the Brain ; the Lateral Ventricles opened 

by an operation. By Wm. Detmold, M. D., of New York. - - 86 

VIII. Notes of Hospital Practice at Bellevue, New York. By D. Meredith 
Reese, M. D., Resident Physician. - - - - - 95 

IX. Notes of Hospital Cases. By Henry Hartshorne, M. D., of Philadel- 
phia. - - - ^ . . . ' . ' . - 108 

X. A Remarkable Case of Double Pregnancy — one Ovum entering the 
Uterus, the other being arrested in the Tube. By Wm. G. Craghead, 
M. D., of Danville, Virginia. (Communicated by Hugh L. Hodge, M. D., 
Professor of Midwifery in the University of Pennsylvania.) - -114 



CONTENTS. 



REVIEWS. 



ART. PAGE 

XI. A Treatise on Fractures in the Vicinity of Joints, and on Certain 
Forms of Accidental and Congenital Dislocations. By Robert William 
Smith, M. D., M.R.I. A., Lecturer on Surgery at the Richmond Hos- 
pital School of Medicine, &c. &c. Dublin, 1847 : 8vo. pp. 314. - -117 

XII. On Infantile Laryngismus, with Observations on Artificial Feeding, 
as a frequent cause of this Complaint, and of other Convulsive Dis- 
eases of Infants. By James Reid, M. D., Member of the Royal College 
of Physicians of London ; Physician to the General Lying-in Hospital, 
and to the Infirmary of St. Giles and St. George, Bloomsbury ; formerly 
Lecturer on Obstetrics and the Diseases of Women and Children. Lon- 
don, 1849 : 12mo. pp. 204. - - - - - - -132 

BIBLIOGRAPHICAL JSTOTICES. 

XIII. A Practical Treatise on the Diseases of Children. By D. Francis 
Condie, M. D., Secretary of the College of Physicians, Member of the 
American Medical Association, Member of the American Philosophical 
Society, Honorary Member of the Philadelphia Medical Society, &c. 
Third edition, revised and augmented. Philadelphia, Lea & Blanch- 
ard, 1850: 8vo. pp. 703. - - - - - - - 147 

XIV. Surgical Anatomy. By Joseph Maclise, Surgeon. With coloured 
plates. Parti. Philadelphia, Lea & Blanchard, 1850: quarto, pp- 40, 
with sixteen plates. _---__., 151 

XV. On the Diseases of Infants and Children. By Fleetwood Churchill, 
M.D., M.R. LA., Hon. Member of the College of Physicians of Ireland, 
Lion. Member of the Philadelphia Medical Society, &c. &c.. Author of 
the *' Theory and Practice of Midwifery," " On the Diseases of Females," 
&c. &c. Philadelphia, Lea & Blanchard, 1850 : pp. 636, 8vo. - - 154 

XVI. A Treatise on Diseases of the Bones. By Edward Stanley, F. R. S., 
President of the Royal College of Surgeons of England, and Surgeon 
to St. Bartholomew's Hospital. Philadelphia, Lea & Blanchard, 1849 : 
8vo. pp. 286. - - - - .-.-,.-. - 1S'<' 

XVII. Principles of Human Physiology, with their Chief Application to 
Pathology, Hygiene, and Forensic Medicine. By William B. Carpenter, 
M. D., F. R. S.\ F. G. S. ; Examiner in Physiology in the University of 
London ; Corresponding Member of the American Philosophical Society, 
and of the National Institute of the United States ; Lecturer on Phy- 
siology at the London Hospital Medical School. Fourth American edi- 
tion, with extensive additions and improvements by the Author. With 
two plates, and three hundred and four woodcuts. Philadelphia, Lea 

& Blanchard, 1850 : 8vo. pp. 750. 160 

XVIII. Observations upon Bulam, Vomito-Negro, or Yellow Fever ; with 
a Review of a "Report upon the Diseases of the African Coast, by Sir 
William Burnet and Dr. Bryson," proving its highly contagious powers. 
By Sir William Pym, K.C.H., Inspector-General of Army Hospitals, 
and Superintendent-General of Quarantine. London, 1848 : 12mo. pp. 
311. 

An Account of the Origin, Spread, and Decline of the Epidemic Fevers of 
Sierra Leone ; with Observations on Sir William Pym's Review of the 
"'Report on the Climate and Diseases of the African Station." By 
Alexander Bryson, M. D., R. N. London, 1849 : 12mo. pp. 174. 

Copy of a Letter of the Superintendent-General of Quarantine (Sir Wil- 
liam Pym) to the Lords of the Privy Council, in reply to Dr. King's Re- 
port upon the BoS, Vista Fever, said to have been introduced into the 
Island by the Eclaire Steamer. Ordered by the House of Commons to 
be printed. August, 1848 : folio, pp. 16. - . - - 161 

XIX. Du Cholera ; moyens Preservatifs et Curatifs ; ou Philosophic des 



CONTENTS. 



ART. PAGE 

Grandes Epidemies. Par A. M. Bureaud-Kiofrey, Docteur en Mede- 
eine de la Faculte de Paris, etc. etc. "In rebus angustis animosus 
atque fortis appare. La medecine eclair^e et le bon sens marchent 
ensemble." Paris and London, 1847 : 8vo. pp. 116. 
Cholera; its Prevention and its Cure; or the Philosophy of Great Epi- 
demics. By A. M. Bureaud-Riofrey, M. D., &c. &c. - - - 171 

XX. Statistics of Cholera ; with the Sanitary Measures adopted by the 
Board of Health prior to, and during the Prevalence of, the Epidemic 
Cholera in Philadelphia, in the Summer of 1849. Chronologically ar- 
ranged. Prepared by the Sanitary Committee, approved by the Board, 
and ordered for Publication, October 10th, 1849. Philadelphia, 1849: 
8vo. pp. 70. 173 

XXI. A Treatise on the Diseases and Special Hygiene of Females. By 
Colombat de L'ls^re. Translated from the French, with additions, by 
Charles D. Meigs, M. D., Prof, of Midwifery and the Diseases of Women 
and Children, in Jefferson Med. College. Philadelphia, Lea & Blanchard, 
1849: 8vo. pp. 720. 177 

XXII. The Transactions of the American Medical Association. Instituted 
1847. Yohll. Philadelphia, 1849 : 8vo. pp. 956. - - - 177 

XXIII. Physician and Patient ; or a Practical View of the Mutual Duties, 
Relations, and Interests of the Medical Profession and the Community. 

By Worthington Hooker, M.D. New York, 1849: 12mo. pp. 453. - 178 



QUARTERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES IN THE 
MEDICAL SCIENCES. 



FOREIGN INTELLIGENCE. 

Anatomy and Physiology. 



PAGE 

1. On the Foetus in Utero, as in- 
oculating the Maternal with the 
Peculiarities of the Paternal 
Organism ; and on the Influence 
thereby exerted by the Male on 
the Constitution and the Repro- 
ductive Powers of the Female. 

By Alexander Harvey, M. D. - 179 

2. On the Production and Disap- 
pearance of Sugar in the Ani- 
mal Economy. By M. Magendie. 184 



PAGE 

3. On the Physiological Anatomy 
of the Spleen. By Dr. W. R. 
Sanders. - - - - .187 

4. On the Medullary Substance of 
Bones. By MM. Gosselin and 
Regnauld. - - - - 188 

5. On the Minute Structure of the 
Papillae and Nerves of the 
Tongue of the Frog and Toad. 

By Augustus Waller, M. D. - 189 



6. On the Blood in Purpura. 
Dr. Parkes. - - _ 



Organic Chemistry. 

I 7. The Transformation of Sugar. 



By 

- 191 



By M. Bernard. 



192 



10 



CONTENTS. 



Materia Medica and Pharmacy. 



PAGE 

8. Medicinal Wines. By Dr. But- 
ler Lane. 192 

9. Manganese as a Succedaneum 

to Steel. By M. Hannon. - 193 

10. Action of Aconitum Napellus. 



PAGE 

By M. Teissier. - - - 194 
11. Galvanic Apparatus for apply- 
ing Chloride of Zinc as a Coun- 
ter-irritant. By Dr. Thomas 
Smith. 194 



Medical Pathology and Therapeutics, and Practical Medicine. 



12. On the Comparative Pathology 
of the Different Races of Men. 
ByM. Boudin. - •■ -195 

13. Movements of the Respiratory 
Organs in Disease. By Dr. 
Sibson. ^ - - - - - 196 

14. Experimental Researches on 
the Action of Quinine, especially 

in large doses. By M. Brecquet. 197 

15. Vegetable Parasites in Dis- 
eases of the Human Body. - 198 

16. The Scrofulous Constitution — 
the signs by v^hich it is known 
— the causes in vrhich it origi- 
nates — its eifects upon families 
and individuals. By Dr. King. 200 

17. Progressive General Palsy. By 

M. Lunier. - - - - 203 

18. Connection between Albumi- 
nous Urine and Degeneration of 
the Kidney in Scarlatina. By 



Dr. Newbigging. - - . 206 

19. On Nervous or Convulsive 
Cough. By M. Sandras. 

20. Neuralgia of the Penis. By 
Dr. Spongier. - 

21. Neuralgia of the Cervix Uteri. 
By M. Malgaigne. - - - 

22. Rheumatic Diseases of the 
Ear. By Mr. Harvey. 

23. Infantile Typhus. By Dr. 
Friedleben. . - - - 

24. On the Pneumonia of Children. 
By M. Valleix. ^ - 

25. Tubercular Meningitis in a 
very young child. By Dr. Rogers. 

26. Cod Liver Oil in Phthisis. - 

27. On Nux Vomica in Impotence 
and Spermatorrhoea. By M. 
Duclos. 

28. Chloroform in Hydrophobia. 
By Mr. S. B. Denton. 



- 207 

- 208 



208 



- 208 



209 

- 211 

212 
212 



213 

214 



Surgical Pathology and Therapeutics, and Operative Surgery. 



29. Singular Distortion of the 
Lower Extremity simulating 
Dislocation of the Thigh Bone. 

By Mr. Warren Einchman. - 214 

30. Osseous Tumours growing from 
the Walls of the Meatus Exter- 
nus of the Ear. By Mr. Joseph 
Toynbee. - 

31. Balsam of Peru as an Appli- 
cation to Indolent Ulcers. By 
E. J. Spry. - . - - 

32. Traumatic Tetanus, treated by 
Chloroform. By Mr. S. G. Slo- 
man. - - - " - 

33. Case of Traumatic Tetanus 
cured by the Destruction of the 
Cicatrix by means of Red Hot 
Iron. By M. Remy. 

34. Further Observations on the 
Treatment of Chronic Inflamma- 
tion of the Bladder by Injections 
of Nitrate of Silver; with Cases. 
By R. L. MacDonnell, M.D. - 



- 215 



217 



- 217 



217 



217 



35. Femoral Hernia, operated on 
with success after Thirteen days' 
Strangulation. By Mr. John- 
ston. - ^ - - - - 218 

36. New Operation for the Treat- 
ment of Vesico-Vaginal Fistula. 

By M. Jobert. - - - - 218 

37. Successful Case of Puncture 
in Hydrocephalus. By Mr, Kit- 
sell. -_ 218 

38. Ovariotomy. By Dr. Charles 
Clay. - - - - - 219 

39. Multilocular Ovarian Cyst, 
weighing forty pounds, success- 
fully removed by operation. By 
Mr. F. Elkington. - - - 220 

40. Successful Case of Ovariotomy 
by the large Abdominal Section. 

By John Crouch, Esq. - - 221 

41. Ligature of the Common Caro- 
tid for Erectile Tumour of the 
Face or Head. By M. Lenoir. 223 



CONTENTS. 



11 



Ophthalmology. 



42. On the Treatment of Sclerotitis 
and Sclero-iritis by Hydriodate 
of Potash. By Robert L. Mac- 
Donnell, M.D. - - - - 223 

43. Symmetrical Swelling of both 



PAGE 

upper Eyelids, resembling (Ede- 
ma, but depending upon Fat. 
By Wm. Bowman, Esq. - - 223 
44. Amaurosis as a Symptom of 
Albuminuria. ByDr. Landouzy. 224 



Midwifery. 



45. On the Mechanical Treatment 
of Sterility. By Henry Oldham, 
M.D. 225 

46. Obesity, simulating Pregnancy. 
Caution in the Diagnosis of 
Pregnancy. By Dr. Leopold 
Schonburgh. - - - - 228 

47. Recovery of an Infant after 
Perforation of its Cranium. By 



229 



By Dr. 



Dr. Lagae. 

48. Ceesarean Section. 
Thomas Radford. - - - 229 

49. Cgesarean Operation successful 
both to Mother and Child. - 231 

50. On Local Bleeding in Displace- 
ment of the Uterus. By M. C. 
OUivier. 232 



Cholera. 



51. Fungoid Origin of Cholera. - 232 

52. Discovery of a Peculiar Cor- 
puscle in the Vomit, Dejections, 
and Sweat of Cholera Patients ; 
and in the Atmosphere of In- 
fected Localities. By Mr. Brit- 
tan. 232 

53. Fungoid Origin of Cholera. . 
By Dr. Nicholas Parker. - - 235 

54. Cholera Sporules. By Mr. W. 

R. Basham. - - - - 238 

55. Report on the Nature and Im- 
port of Certain Microscopic 
Bodies found in the Intestinal 
Discharges of Cholera. - - 239 

56. Analyses of the Blood, Matters 
vomited, Alvine Evacuations, 



and Urine of Cholera Patients. 
By M. Becquerel. - - - 246 

57. Observations on the Urine in 
Cholera. By James W. Begbie, 

M. D. - - - - - 249 

58. On the Non-existence of Bile 
in the Stools of Cholera, and in 
the first Urine secreted after the 
Algide Stage. By Prof. Parkes. 253 

59. Abstract of Observations made 
in the Cholera Hospital at Ley- 
den, during November and De- 
cember, 1848, and January, 
1849. By Dr. F. J. J. Schmidt. 255 

60. Calomel Treatment of Cholera. 

By Dr. H. M. Hughes. - - 258 



Anesthetic Agexts. 

61. Death by Chloroform. ByDr. Confevron. - 

Medical Jurisprudence and Toxicology. 

62. On the Medico-Legal Appro- | By M. Bayard, 
ciation of Ether and Chloroform. 



258 



- 260 



AMERICAN INTELLIGENCE. 

Original Communication. 



Remarks upon the Presence of 
some Infusoria in the Tissues 
and Secretions of Patients dying 



of Cholera. 
M.D. 



By W. I. Burnett, 



261 



12 



CONTENTS. 



Domestic Summary. 



PAGE 

Descriptions of three new Genera 
of Entophyta, growing from the 
Mucous Membrane of the Small 
Intestine of Julus, and from the 
Exterior Surface of Entozoa in- 
festing that cavity ; and also of 
some new Genera and Species 
of Entozoa. By Joseph Leidy, 
M. D. - - - - - 263 

Irritation of the Ketina from Ir- 
ritation of Dental Branch of 
Fifth Pair of Nerves. By Dr. 
Hays. - - - - - 270 

On the Use of Chloroform in Pe- 
riodical Neuralgia. By Daniel 
Brainard, M. D. - - - 272 

Ossification of the Superior Lobe 



PAGE 

of the Eight Lung. - - - 273 

Remarks on Ozone, and its sup- 
posed influence in the production 
of Epidemic Diseases, especially 
of Epidemic Cholera. By Robert 
Peter, M. D. - - - - 274 

Wound of the Brain — Recovery. 
By William Kenney, M. D. - 275 

Amussat's Operation for Artificial 
Anus. By Prof. J. M. Bush. - 275 

An Account of the First Use of Sul- 
phuric Ether by Inhalation as 
an Angesthetic Agent in Surgi- 
cal Operations. By C. W. Long, 
M. D. 276 

Tribute to the Late Prof. J. P. 
Harrison, of Cincinnati. - - 277 




^^^^ 



THE 

AMEEICAN JOUENAL 
OF THE MEDICAL SCIENCES 

FOE JANUARY 1850. 



Art. I. — Observations on the Prevention of Phthisis, and its proper Treatment 
in the Early Stage, with Cases illustrating its Natural History. By Edward 

. Hallowell, M.D., Fellow of the College of Physicians of Philadelphia ; 
Member of the Academy of Natural Sciences, &c. 

It is questionable whether phthisis occurs to any extent among the Abo- 
rigines of North America, or of other countries. Dr. Rush denied its existence 
among the former.* It is a subject of regret, that proper attention has not 
been paid by the medical staff attached to the several exploring expeditions 
ordered by our government, to the diseases of the Aborigines. Probably no 
definite instructions to this effect were given. The interests of civilization and 
of humanity would be promoted by reliable information of this kind ; and it 
is hoped that, in future, a person fully competent, may be appointed to ac- 
company each expedition, whose duty exclusively it shall be to study the dis- 
eases of the natives. No detailed account of the autopsy of an Indian has 
ever been published. 

The only passages that we have observed which allude to phthisis, in the 
Narrative of the U. S. Exploring Expedition, are the following: — 

The King's Mill Islanders. — "From diseases the natives appeared to be tole- 
rably free ; consumption, and a kind of cholera morbus, are the most fatal.^' — 
U. S. Exploring Expedition, vol. v. p. 104. 

Tongataboo. — "The diseases of this climate are influenza, colds, coughs, and 
consumption." — Vol. iii. p. 33. 

Feejee Group. — "Of phthisis pulmonalis, Dr. Fox did not see a case, and he 
thinks it must be rare." — Vol. iii. p. 329. 

* Phthisis, no doubt, occurs amons; the half breeds and other Indians that have had 
much intercourse with the whites. Cln-onic pleurisy, from the variable condition of the 
climate and want of proper attention, must also be frequent, even among the Indian? 
of unmixed blood, and may have been mistaken for phthisis. For an interesting 
letter, from Dr. Z. Pitcher, "on the existence of pulmonary consumption among the North 
American Indians," see Dr. Morton's " Illustrations of Pulmonary Consumption,''^ 2d edit, 
p. 309. 

No. XXXVIL— January, 1850. 2 



14 Hallowell on Tubercular Diseases. [Jan. 

De Fuca's Straits. — " The diseases most often met with are bronchitis and 
tubercular consumption. Dr. Ilohiies saw an old man in the last stage of con- 
sumption, shivering from the eiFects of a cold bath, at the temperature of 40° 
Fahrenheit."— Vol. iv. p. 482. 

Dr. Ernest Dieffenbach, who travelled among the New ZealanderS; in the 
year 1839^ states : — 

^^That before that people became acquainted with Europeans, they were 
uniformly healthy, if we may trust their own accounts and those of the 
earliest navigators v/ho visited them. Their first visitors describe them as 
possessed of that energy of frame, and exuberance of health and animal 
spirits, which we may always expect to find where a people are untainted by 
the evils which seem to be the necessary companions of civilization ; where 
they are living in a moderate, although invigorating climate ; where they are 
not sufi'ering from actual want ; and where they are forced to satisfy their ne- 
cessities by the exercise of their physical and mental powers. It would have 
been contrary to the laws of nature for them to have been entirely free from 
illness; but their diseases were those of an inflammatory and epidemic charac- 
ter." " In former times, the food of the natives consisted of sweet potatoes, taro 
(caladium esculentum), fern root (Pteris esculenta), the aromatic berries of the 
kahikatea (Dacrydium excelsum), the pulp of a fern tree (Cyathea medullaris), 
called korau or mamako, the sweet root of the Dracaena indivisa, the heart of 
a palm tree (Areca sapida), a bitter though excellent vegetable, the Sonchus 
oleraceus, and many different berries. Of animals, they consumed fishes, dogs, 
the indigenous rat, craw fish, birds, and guanas. Rough mats of their own 
making, or dog skins, constituted their clothing. They were hardened against 
the influence of the climate by the necessity of exerting themselves in procuring 
their provisions, and by their frequent privations and travelling excursions, 
which produced a healthy excitement, and vfith it an easy digestion of even this 
crude diet. This state of things has been gradually changed since the Eu- 
ropeans arrived in the country. They have given them the common potato, a 
vegetable which is produced in great cjuautities and with little labour; and, as 
this labour could be mostly done by the slaves or by the women, potatoes be- 
came the favourite food of the Aborigines. They preferred feeding upon them 
to procuring what was far more wholesome, but gave them more trouble in 
obtaining. Instead of being constantly in bodily exercise, they became read- 
ers, an occupation very much suited to their natural indolence. Their nume- 
rous dances, songs, and games were regarded as vices, and were not exchanged 
for others, but were given up altogether. The missionaries, while abolishing 
the national dances and games, might with safety have introduced those of 
England, which would soon have become great favourites with them. In one ,, 
word, instead of an active, warlike race, they have become eaters of potatoes, 
neglecting their indastrious pursuits, in consequence of the facility of procur- 
ing food and blankets; and they pass their time in eating, smoking, and sleeping. 
Potatoes are unwholesome if they form the only food, and if those who live 
upon them do not use great bodily exercise. From the exclusive use of pota- 
toes, prominent paunches begin to be common among children, which are by 
no means natural to the men, and are not met with among the tribes in the 
interior. Diseases of the hip-joint and of the spinal column, and distortions of 
the spine in early infancy, even now are not rare." — Travels mJVeio Zealand, 
vol. ii. chap. ii. (London). 

The following observations respecting the Friendly Islanders are made by 
Capt. Cook. "The natives of the Friendly Islands seldom exceed the common 
stature (though we have measured some who were above six feet), but are very 



1850.] Hallowell on Tuhercular Diseases. 15 

strong and well made, especially as to tlieir limbs. They are generally broad 
about the shoulders; and, though the muscular disposition of the men, which 
seems a consequence of much action, rather conveys the appearance of strength 
than of beauty, there are several to be seen who are really handsome. Their 
eyes and teeth are good. Though the features of some (of the women) are 
so delicate as not only to be a true index of their sex, but to lay claim to a 
considerable share of beauty and expression, the rule is by no means so general 
as in many other countries. But, at the same time, this is the most exception- 
able part, for the bodies and limbs of most of the females are well propor- 
tioned, and some absolutely models of a beautiful figure. But the most 
remarkable distinction in the women is the uncommon smallness and delicacy 
of their fingers, which may be put in comparison with the finest of Europe. 
Phthisis is not mentioned as existing among them. The graceful and firm step 
with which the people walk is not the least obvious proof of their personal 
accomplishments. They are frank, cheerful, and good humoured, though some- 
times, in the presence of their chiefs, they put on a degree of gravity, and 
such a serious air as becomes stiff and embarrassed, and has the appearance of 
reserve. ^^ — Cook's Voyages to the Facijic Ocean, vol. i. p. 380, quarto edit. 
(Lond. 1784). 

Col. Long states ^^ that the catalogue of diseases among the Omahaws is 
infinitely less extensive than that of civilized man. No case of phthisis, or 
of jaundice,^' he observes, " fell under our observation. King's evil is not un- 
common. Decayed teeth are rare ; confirmed insanity appears to be unknown." 
— Long's Expedition to tlie Rocky Moiintains, vol. i. p. 264 (Phila. 1823). 

^' Consumption among the natives of Ceylon," according to Dr. Davy, 
"rarely appears. It occurs most frequently among the descendants of the 
Dutch and Portuguese, who, in very many instances, have weak frames and 
ill-formed chests, and appear to be particularly liable to this disease." — 
_An Accou7it of the Interior of Ceylon and its Inhahitants, by John Davy, 
M. D., F.E. S. (Lond.). 

Of the natives of New South Wales, it is said : — 

"En general, ils se retablissent tres promptement de leurs blessures; une 
fracture du crane ne les arrete memo que tres peu de temps." — "Les maladies 
des enfans [sont] presque entieremeut inconnues a la Nouvelle Gralles du Sud. 
Les ophthaimies, la dysenteric, les catarrhes sont les affections qui s'observent 
le plus frequemment. La consomption, sans etre tout-a-fait meconnue, se 
montre cependant Cjuelquefois, et moissonne un petit nombre de jeunes Creoles. 
On a remarque qu'en general les maladies avaient a Port Jackson une carac- 
t^re plus aigue qu'en Augleterre." 

" Quoique moins grands que les Yolofs, les Malgaches ou indigenes de 
Madagascar sont cependant mieux faits qu'eux; leur peau est d'une nuance 
moins foncee, leurs traits agreables, leur regard affable et spirituel; ils sont 
adroits et fort agiles. On en connait piusieurs castes, chez iesquelles la cou- 
leur, la tailie, les formes, les cheveux, le caractere varient singulierement. 
Les femmes Malgaches sont pour la plupart d'un physique gracieux, d'un 
caractere bon et timide; elles ont la tailie bien prise, la gorge bien fliite, 
quoique peu developpee, les yeux beaux, la main delicate, mais le pied grand et 
plat. Dans les tribes des Ovas surtout elles sont tres jolies." — Voyage de U As- 
trolabe, t. i. p. 468. 



16 Hallo well on Tubercular Diseases. [Jan. 

The preceding observations go to prove that the tendency of civilization, 
and especially of the congregation of large masses in cities, is to deteriorate 
the general health ; but it is to be lamented, as before remarked, that we have 
not more positive information upon the subject. For much statistical know- 
ledge in regard to the health of the inhabitants of towns, we are indebted to 
our English brethren. The reports of the Commissioners made to Parliament 
show that the average duration of life is greater in the country than in cities, 
and that in the latter, the mortality in narrow streets and in ill-ventilated 
houses and apartments, is greater than in those which are broader, and in 
more spacious dwellings. In Great Britain, the nobles attain the longest life. 
Whether the same degree of health exists among the best educated and most 
wealthy of our own country, we have at present no means of determining. It 
would be interesting and important to trace the relations between the habits 
of life and modes of thought of different classes in diiferent countries, and 
the duration of their health. A French writer makes the following observa- 
tions in regard to two towns in the East not very remote from each other: — 

" Pondicherry, pauvre et a peine peuplee, est cependant encore le sejourde 
la gaieteet des plaisirs. Madras, avec ses palais, ses richesses, et sa popula- 
tion, est celui de la tristesse et du ceremonial. En vain je cherchais sur les 
physiognomies des dames Anglaises une lueur de gaiete. Sur leurs figures 
pales et amaigries, je ne trouvais que de T ennui et le degout. Quelle Fran- 
§aise voudrait acheter Fopulence qui les entoure au prix d'une semblable 
existence; echanger les plaisirs de la societe, cette douce urbanite de nos 
moeurs, centre Tisolement, et surtout la froide etiquette a laquelle dans I'lnde 
la vie d'une ladi/ semble consacree ? Une promenade dans son brillante equip- 
age, sur le bord de la mer, vient finir une journee presque entierement passee 
dans les appartemens interieurs. En vain elle espere que Tair moins chaud 
du soir ranimera ses forces epuisees par la chaleur et le repos continuels; mais 
non, elle rentre plutot ennuyee que fatiguee, pour paraitre aussi pale que le 
matin a une table dont elle ne fait nullement les honneurs : le dessert I'en- 
cliasse ; et pendant que les hommes, restes seuls, passent plusieurs heures a 
s'enivrer, la maitresse de la maison se retire chez elle, ou va se preparer pour 
une soiree, dont, suivant Fetiquette, I'invitation date d'un mois. Dans ces 
reunions, les figures, graves et roides, semblent remplir un devoir et non pas 
jouir d'une agreable distraction : les danseuses et leuYS partners portent dans 
les eternelles colonnes cette meme gravite ; le bal conserve j usque a la fin la 
meme froideur qu'au commencement — nulle gaiete, aucun abandon ; tout 
annonce que Ton s'est reuni sans plaisir, et que Ton se separera sans regret. 
Madras, ne possedant pas de theatre, les autres soirees n'amenent pas encore 
d' aussi vivos distractions : alors les dames, isolees dans leurs grands apparte- 
mens, eprouvent le plus souvent tout ce que Tennui pent avoir de plus accablant. 
Elles n'ont pas leurs enfans pour les distraire ; a peine sortis de leur premier 
enfance, ils ont ete envoyes en Europe pour echapper aux maladies que les 
eussent devores : heureuse la mere qui pent les suivre ', elle evite le danger 
de ne les revoir jamais ! Si elle reste, sa sante s'affaiblit de plus en plus ; la 
cruelle maladie de poitrine Tentraine rapidement au tombeau ; et cette jeune 
femme, venue fraiche et belle d'Angleterre, va mourir dans quelque etablis- 
sement sur la cote malsaine dont le climat moins brulant lui promettait en vain 
le re tour vers la sante. Telle fut la destinee d^ Eliza de Sterne dont Haynal 



1850.] Hallowell on Tubercular Diseases. IT 

aclieva de rendre le nom immortel. Le comptoird'Aujinga I'avait vue naitre, 
Aujinga la vit expirer, a la fleur de son age, sous I'influence d'un climat de- 
vorant. 

"Est-ce la vie trop sedentaire des dames Anglaises que doit etreattribue le 
sort malheureux qui les attend presque toutes apres quelques annees de sejour 
dans rinde, ou bien a la difference du climat de ces contrees voisines de 
TEquator avec le climat froid et humide de T Angleterre ? I'une et I'autre cause 
pourrait etre admise ; car, dans nos comptoirs, sur les memes influences, les 
families Frangaises se sont parfaitement conservees, les enfans ont ete eleves 
dans le pays, et si les jeunes femmes n^ont pas les couleurs briilantes, ni la 
blancheur des femmes de leur ancienne patrie, elles en ont conservee la beaute, 
la grace, et la gaiete. 

" Si r existence des liommes est plus active, et moins monotone, leur fin n'est 
pas moins sou vent mallieureuse. Ignorant des jouissances de la societe privee, 
de ces liaisons d'amitie qui font cliez notre nation la bonlieur de la vie, ils 
usent leur existence a table; Tabsence des distractions les livre a des exces 
que les femmes, touj ours loin de leurs regards, ne pen vent arreter; bientot 
leur sante se derange, et les obstructions au foie viennent terminer une vie 
vouee des long temps aux souffrances et au degout. Combien ai-je reconter 
dans le cours de mon voyage d'employes de la compagnie rassasie de richesses I 
lis venaient mendier la sante aux climats temperees de la Chine, et de la 
Nouvelle HoUande; ils ne trouvait qu'un tombeau!'' — Voyage autoiir du 
3Ionde sur la Corvette la Favorite, sous la commandemeiit de M. La. Place, 
tom. i. p. 247 (Paris). 

There can be no doubt that national peculiarities and customs influence in 
a marked degree the health and happiness of a people. How difierent the 
traits which distinguish the sedate and inactive Mahometan from the lively 
Frenchman, or the busy inhabitant of our New England States ! Not only 
those peculiarities, which are so prominent, but the social habits and conven- 
tionalities of life produce a well-marked influence upon the health of com- 
munities. Hence the importance of a physician being familiar with other 
subjects than those bearing directly upon his daily pursuits. He should be a 
close observer of society in all its aspects, and be acquainted with its forms, 
not only in his own, but in other countries. The influence of the mind upon 
the body is so great that whatever adds to the happiness of the individual 
invigorates his health. We are inclined to believe that the restless search after 
gain, and the ambitious spirit, that distinguish the majority of our countrymen, 
operate injuriously upon both. Few, at least, exhibit the outward evidences of 
them, and but few, we believe, attain to old age. Let any one stand at the 
door of a thronged church, in any of our large cities, and observe the vast 
number of anxious and careworn countenances and meagre frames which 
emerge from them, with but here and there an exception, and he will be con- 
vinced that, outwardly at least, we do not exhibit the signs of a hapj^y and 
contented people. Almost the only exceptions are the young of the gentler 
sex, who appear to be careless and insouciant. We have no means of judging 
positively, but believe that phthisis is more common in this country, arising 
from the neglect of hygienic preventives, and from the constant care and anxiety 
hat exist in almost all classes, than in the corresponding ranks in Europe. 



18 Hallowell on Tubercular Diseases. [Jan. 

The importance of careful training, in the development of physical and 
mental traits, is shown in the great advantages derived from it in the inferior 
animals. The following observations are made in a recent French work : — 

^^ Avant M. Hamont, un Turk dirigeait les haras, mais dans un autre bati- 
ment; car celui dont nous parlons a ete construit sur les plans de notre habile 
compatriote. A cette epoque, on liait les chevaux par les quatre pieds dans 
les ecuries. Leur nourriture etait mauvaise. Cinq mois durant, la vielle 
coutume les attachait jour et nuit au milieu d'un champ de trefle. Le reste 
de I'annee, sans autre menagement, et sans transition, ils etaient mis au re- 
gime de Torge et de la paille. Qu'arrivait-il ? C'est que sur deux cents 
juments on obtenait cinquante poulains, soixante a peine, encore naissaient-ils 
chetifs et restaient-ils de taille mediocre parce que le hazard se chargeait k- 
peu-pres seul des appareilmens. M. Hamont a change des I'abord ce pitoy- 
able systeme ; aussi le nombre des naissances s'est il accrue d'une mani^re 
inesperee : il a obtenu quatre-vingts et j usque quatre vingt-dix poulains par 
cent femelles. Mieux soignes qu'auparavant, les poulains sent devenus plus 
beaux; enfin, apres plusieurs annees, et par Tefiet des croissements successifs, 
on a eu des produits superieurs, des chevaux qui joignent ^ la taille necessaire 
les qualites precieuses des etalons nejdis qui les avaient engendres." — Voyage 
en Ahysdnie, par MM. Ferret et Galinier, p. 135 (Paris, 1847). 

The fine appearance of the English nobles is said to be attributable^ in a great 
degree, to the avoidance of the practice of " breeding in and in.^' A noble- 
man often marries a woman of inferior rank, but remarkable for health 
and beauty. Mental as well as physical characteristics are, no doubt, often 
hereditary. Instructors of youth observe a marked difference between the men- 
tal endowments of the children of the cultivated, and of those who are not. 

One of the most important means of preventing the development of phthisis 
is the free admission of air into dwellings. Our State governments should 
prohibit the erection of buildings that do not meet the requirements for the 
maintenance of a healthy race of operatives. Not only their own interests, 
but those of other classes, reacted upon by them, demand such a prohibition. 
It has been recommended that those of the poor who marry — and the same 
advice might be given to others — should select habitations that contain apart- 
ments which are large, and to which the air has free access. A vigorous off- 
spring cannot be had by unhealthy parents. The progeny may be numerous, 
but will be unhealthy. The early marriages in this country are a great evil. - 
The mother, for the most part with a fragile constitution, is worn out by nu- 
merous births ; and, by the care and attention given to the children, becomes a 
mere drudge. In society, she is rarely seen, and her influence is unfelt — she 
too often, in a few years, exhibits the marks of premature old age. 

The art of swimming is highly conducive to health. Every boy and girl 
should be taught to swim. At the age of puberty, especially, it is important. 
Every home should be provided with the means of obtaining warm and cold 
baths, and a bath be had twice a week, at least. Cleanliness, observes Dr. 
Kush, is a virtue ; of the truth of which sentiment, there can be no doubt. 
Its effects upon the mind are as wholesome as upon the body, inducing cheer- 

v 



1850.] Hallowell on Tubercular Diseases. 19 

fulness and activity. Much of the unhappiness of the poorer classes^ and of 
their disposition to vice, arises from the want of cleanliness in their houses and 
persons; a truth which should be remembered by philanthropists, who, when 
they give religious advice and instruction, important as these no doubt are, too 
often fail to see that the Divine injunctions are carried into effect. The admis- 
sion of light into dwellings is also of great service. Children born in mines are 
often rickety, and otherwise deformed. Baron Dupuytren succeeded in curing a 
number of his patients, by removing them to a part of the town to which the 
sun had free access. The practice, too common, of excluding light from our 
houses, is no doubt injurious to health. The influence of light is felt, in a 
marked degree, by the lower animals. " If the general development of the 
tadpole be retarded by keeping it in a cold, dark place, and if hereby the 
functions of the blood-corpuscles be slowly and imperfectly discharged, they 
will maintain their embryonic state for several weeks later than usual." — 
KirJce and Paget s Physiologij, p. 227, Amer. ed. A nutritious diet is also 
of great importance. Prof. Jackson, in a recent number of the American 
Journal of Medical Sciences,^ has pointed out the evils arising from the too 
exclusive consumption of tea, especially by children. The more general use 
of nourishing soups, made in the best manner, would be highly advantageous. 
Several medical friends, in extensive practice, have told me that they have 
found those families in which the consumption of soup was habitual more 
healthy than those that have not had it, or but occasionally — a fact which my 
own experience has confirmed. 

It is a prevalent opinion that the body, being the less noble part, re- 
quires but little attention, which is certainly a very mistaken notion. f The 
best man will often be found to be the most healthy. The healthy condition 
of the organs enables the mind to act more eihciently, and certainly with 
more satisfaction. It is impossible to be a very efficient and active member 

* No. XXXV. New Series, 1849. 

t " La beaute est une piece de grande vecommendation aux commerce des hommes; 
c'est le premier moyen de conciliation des uns aux aultres, et n'est homme si barbare at 
si recbigne qui ne se sente aulcunement frappe de sa doulceur. Le corps a une grande 
part a nostre estre, il y tient un grand rang; ainsi sa structure et composition sont de 
bien juste consideration. Ceulx qui veulent desprendre nos deux pieces principales, et les 
sequestrer i'une de I'aultre, ils ont tort: aurebours, ii les fault r'accoupler et rejoindre; il 
fault ordonner a Tame non de se tirer a quartier, de s'entretenir a part, de mespriser et 
abandonner le corps (aussi ne le s9auroitelle faire que par quelque singerie contrefaicte), 
mais de se r'allier a luy, de Terabrasser, le clierir, luy assister, le contrerooller, le conseiller, 
]e redres^er, et ramener quand il fourvoye, I'espouser en somme, et luy servir de mary, 
a ce que leurs effects ne paroissent pas divers et contraires, ains accordants et uniformes. 
Les chrestiens ont ime particuliere instruction de cette liaison: car ils scavent que la 
justice divine embrasse cette societe et joincture du corps et de fame, jusques a rendre 
le corps capable des recompenses eternelles; et que Dieu regarde agir tout I'liomme, et 
veult qu'entier il receoive le chastieraent, ou le loyer, selon ses demerites. La secte 
peripatetique, de toutes sectes la plus sociable, attribue a la sagesse ce seul soing, de pour- 
veoir et procurer en commun le bien de ces deux parties associees: et montrent les aul- 
tres sectes, pour ne s'estre assez atlachees a la consideration de ce meslange, s'estre par- 
tialisees, cette cy pour le corps, cette aultre pour Tame, d'une pareille erreur; et avoir 
escarte le subject, qui est rHomnie; et lenr guide, qu'ils advouent en general estre Na- 
ture.'' — Montaigne, chap. xvii. 



20 Hallowell on Tubercular Diseases. [Jan. 

of society, without a large stock of health ; and its possession should be an 
object of primary importance with every rational being, so that, having it, he 
may add not only to his years, ^-but to his life,^^ for life consists not so much 
in length of years as in the enjoyment arising from the consciousness of years 
spent in the best possible manner. 

"Une vie sobre, moderee, simple, exempt d'inquietudes et de passions, 
reglee et laborieuse, retient dans les membres d'un homme sage, la vive 
jeunesse, qui, sans ces precautions, est toujours prete a s'envoler sur les ailes 
du temps/' 

The same author (Fenelon), enumerating the virtues to which the Mandu- 
rians attached the most value, places health the first. 

^^ Ce que nous estimons c'est la sante; la frugalite, la liberte, la vigueur de 
corps et d'esprit; c'est Tamour de la virtu, le crainte des Dieux, le bon naturel 
pour nos proches, I'attachement a nos amis, la fid elite pour tout le monde, 
la moderation dans la prosperite, la fermete dans les malheurs, le courage 
pour dire toujours hardiment la verite, Thorreur de la flatterie." — TelemaquCj 
liv. X. 

The proper regulation of the passions, and even of the affections, is of the 
utmost importance in the preservation of health. For the want of the latter, 
women often suffer much ; not because their minds are by nature inferior to 
those of men, but because in them the intellectual faculties, as well as phy- 
sical powers, rarely receive the cultivation and development of which they are 
susceptible. No human being can be too highly educated — a sound education 
and the happiness of the individual are inseparable. 

One of the most prominent causes of ill-health is want of suitable relaxa- 
tion. Unfortunately for our countrymen, the love of the beautiful does not 
appear to be a prominent mental characteristic. Chateaubriand says of the 
Americans that, although fond of the study of natural history, they have no 
love for the beauties of nature. This is, no doubt, an error ; but we question 
much whether the love of it is as deep or intense as in the more cultivated 
nations of Europe. The sexes are much more rarely brought together with a 
view to social refinement; and, although feminine beauty is far more common 
in the young than in most other countries, it is often passed by without notice. 
Woman, in the United States, is a subject of regard, but is seldom adored. 
In England, the love for natural objects, even inanimate, is often strong even 
among the poorer classes. In the Appendix to the very remarkable work on 
Modern Painters,* is the following note: "The reader will probably recollect 
the Sonnets of Wordsworth, which were published at the time when the bill 
for the railroad between Kendall and Bowness was laid before Parliament. 
His remonstrance was, of course, in vain ; and I have since heard that there 
are proposals entertained for continuing this line to Whitehaven through £or- 
rowdale. I transcribe the note prefixed by Wordsworth to the first sonnet : 
' The degree and kind of attachment which many of the yeomanry feel for 

* Modern Painters, by a Graduate of Oxford, p. 220. 



1850.] Hallowell on Tubercular Diseases. 21 

their small inheritances can scarcely be overrated. Near the honse of one of 
them, stands a magnificent tree, which a neighbour of the owner advised him 
to sell for profit's sake. ^Tell him/ exclaimed the yeoman, ^I had rather fall 
on my knees and worship it.' " There is probably not one person to be found 
in our Northern States who would utter such a sentiment. 

It would be interesting to know statistically whether phthisis exists in any 
great degree in our Southern States. I am informed by Prof. Holbrook that, 
in the higher ranks of society in Charleston, it is rare. It is an evidence of 
feeble, or of inferior organization, wherever it exists. It is most common in 
feeble men, in women and children, in blacks, and in the quadrumanous 
animals.* Whatever depresses or debilitates has a tendency to induce it. 
Attendance upon sick relatives, if prolonged, often causes it. Suppressed 
emotions, no doubt, give rise to it, especially in women. Seclusion from 
society is another cause. Persons find, in their intercourse with the world, 
much insincerity ; and disgusted with human nature, keep aloof from their 
kind, and die, for man is naturally a social being. A more genial spirit, and 
more confidence in others, would have saved them. Perhaps this is more 
common in commercial, than in other communities. The mortality from 
phthisis in our Eastern Penitentiary, among those engaged in sedentary em- 
ployments, the shoemakers, for instance, is very high. Reformation being 
the object desired in the seclusion of the prisoner, the greatest care should be 
taken lest his life become a sacrifice to the means employed. Lounging and 
sedentary habits, too great a love for books, and much unprofitable thinking — 
which, properly speaking, is no thinking at all — may likewise induce it. 

Phthisis is a disease of the blood, which, from the long continuance of 
various debilitating influences, becomes deteriorated, and tubercular matter 
is separated from it. Hence, the importance of nourishing the system well, 
especially in those predisposed to the disease. Early rising, regular habits, 
exercise in the open air, a diet consisting chiefly of animal food, the avoidance 
of sedentary employments and mental anxiety, with free ventilation in uncon- 
fined streets, are necessary, and desirable, indeed, for ail, whether predisposed 
or not. 

Tuhercular Meningitis. — This is a disease ot)served, for the most part, in 
children. The term meningitis is employed, from the predominance of the 
cerebral symptoms; but the tubercular deposit is found in almost every organ 
in the body, difi"ering in this respect from the same affection in the adult, in 
which it exists chiefly in the lungs. For an account of the symptoms of this 
disease, see Rilliei et Bartliez {^Traite Cliniqiie et pratiques des Maladies des 
Enfans, tom. iii. p. 493). 

* An ingenious friend, Mr. John Cassin, attributes the mortality among these animal?, 
in our menageries, in part to the fact of their being fed exclusively upon fruits and vege' 
tables, they being, in a state of nature, insectivorous. See Proceedings of Acad. Nat. 
Sciences, vol. iv. ])age 3. It is probable that [ew, if any, animals die of phthisis in 
their native haunts. 



22 



Hallowell on Tubercular Diseases. 



[Jan. 



The following is a summary of the differential symptoms in simple and 
tubercular meningitis, as laid down by Dr. Eilliet (Provincial Medical and 
Surgical Journal, 1847, p. 234) : — 



SIMPLE MENINGITIS. 

1. The children attacked are in general 
vigorous and well developed, and do not 
exhibit any signs of tubercle. The rela- 
tives, too, are healthy. 



2. The disease may appear as an epi- 
demic. 

3. Prior Condition. — The attack takes 
place during robust health; or, if it is se- 
condary, it follows some palpable external 
cause, or arises in the course of a non- 
tubercular malady. 

4. Mode of Attack. — Violent convulsions, 
intense fever, quick inspiration, if the in- 
fant is very young; or headache, fever, 
bilious vomiting After a lapse of twenty- 
four hours, excessive agitation, delirium, 
and prostration. 



5. Symptoms. — Headache intense- vo- 
miting incessant: fever high; delirium 

fierce : constipation moderate. 

6. Progress. — Rapid, convulsions inces- 
sant. 

7. Duration. — Death in twenty-four hours, 
in some cases, but generally at the end of 
the third day. 



TUBERCULAR MENINGITIS. 

1. The subjects of tubercular meningitis 
are delicate, and often precocious cliildren. 
They are subject to glandular enlargements, 
and chronic eruptions of the skin. The 
blood relatives generally bear the stamp of 
the strumous diathesis. 

2. The disease is always sporadic, 

3. Prior Condition. — The infant is ob- 
served to pine away, and lose its flesh and 
strength. The disposition is altered, the 
appetite fails, and the prirncz vice becomes 
deranged. 

4. Mode of Attack. — Convulsions never 
the first symptoms ; the transition from the 
■first to the second period of the disease in- 
sensible; the coming on of the second stage 
marked by headache, vomiting, and consti- 
pation ; the intelligence sometimes unaf- 
fected. When the precursory symptoms 
are absent, the disease is ushered in by vo- 
miting, moderate headache, and fever. 

5. Symptoms. — Headache not intense; 
vomiting not so urgent; constipation obsti- 
nate ; fewer moderate. 

6. Progress. — Slow. 



7. Duration. — More prolonged ; 
night to three weeks. 



fort- 



Treatment. — In tubercular meningitis, nugatory. Those affected with this 
disease necessarily die. In the early stage of phthisis, the same hygienic '*>^<^ 
treatment is to be pursued as for its prevention. There is abundant evidence 
to show that, in this stage, the disease is curable. Among the most import- 
ant means, is removal to a southern climate. An eminent medical friend, re- 
markable for uniform good health, who, in the early part of his life, resided 
in the North (U. S.), informs me that he lost a brother and one parent from 
phthisis ; and he attributes his present excellent health to living in the South, 
and adopting southern habits. Another friend enjoyed, during a long resi- 
dence in the South, uninterrupted health, which, though he was remark- 
able for his vigorous and healthy appearance, he lost on his return to 
this city. A sister, resident in one of the Northern States, always in delicate 



1850.] Hallowell on Tubercular Diseases. 23 

health, has lost all her children, seven in number, from phthisis. Such in- 
stances might be multiplied greatly. The difference is induced, not only by 
the climate, but by the habits of the people, which are more in accordance 
with nature ; and there can be no doubt that the inhabitants of our Northern 
States would enjoy better health, were they to encourage, to a certain extent. 
Southern habits. They might not acquire so much wealth, but they would be 
improved physically as well as mentally. 

But little is to be attained by the employment of drugs in the early stage 
of phthisis. It is best to avoid their use. If a cure is to be accomplished, 
it is by the aid of hygienic measures. This was the opinion of the late Dr. 
Parrish, based upon a long experience ; and, in a recent conversation with the 
venerable Dr. James Jackson, of Boston, than whom it would be difficult to find 
a higher authority, I was happy to learn that similar views were entertained 
by him. Riding on horseback, agreeable diversion of mind, free from excite- 
ment, the pure air of the country, moderate exercise on foot, not carried to 
fatigue, but, above all, removal to a genial climate and atmosphere, are im- 
portant elements in the successful treatment of this much-dreaded disease. 

Cases of Tubercular Menmgitis. — Case I. — June 7th, 1839. Made to-day 
the autopsy of a male child (E. C., 9et. 10 mo). The father of this child 
is now confined to his room with phthisis, and is not expected to live through 
the ensuing winter. The mother, who is healthy, states that the child had 
been well up to the 22d ult., with the exception of a slight bowel-complaint, 
which lasted only a day or two, for which he took a dose of castor oil and some 
syrup of rhubarb. On the 22d, he was observed to be drowsy, and continued 
in this state, the stupor increasing, until the 25th, when he was attacked with 
convulsions, which affected the left upper and lower extremity; a day or two 
before his death, there were convulsive movements of the right arm, with para- 
lysis of the left side ; there was no vomiting in the commencement; it occurred 
at a subsequent period, but lasted a short time ; there was also no diarrhoea. 
He had no cough previous to his illness. He was leeched, and took calomel. 
Treatment for hydrocephalus. 

AutopsT/, June 7th, twenty-four hours after death. — Exterior pale, with the 
exception of the posterior parts of the body, which are mottled from position ; 
not emaciated; no oedema of feet or ankles. 

Head. — Very little blood exterior to the dura mater, and but a small quan-,' 
tity in the longitudinal sinus; veins of pia mater moderately distended; 
arachnoid dry, slightly opaque, no effusion beneath; pia mater moderately 
injected, the injection being confined to the larger vessels; beneath the arach- 
noid, upon the upper surface of the brain, are observed a very considerable 
number of opaque yellowish granulations, about the size of millet seeds ; they 
appear to follow the course of the vessels, and are most abundant in the fissure of 
Sylvius; pia mater of base much injected; the injection is much greater upon 
the base of the right hemisphere than on the opposite side; there is a con- 
siderable quantity of yellowish tuberculous matter deposited around the com- 
missures of the optic nerves, with opacity and thickening of the arachnoid in 
this spot; convolutions flattened; cortical substance pale ash colour, not in- 
jected ; in the centre of the anterior lobe of the right hemisphere, there is a 
well-marked softening ; it has a yellowish tinge, and is almost diffluent ; at 



24 Hallowell on Tuhercular Diseases. [Jan. 

the bottom of it^ there is a small sanguineous effusion of a brick dust colour; 
the line of demarkation between the softened portion and that which is more 
healthy is very evident; there is also an evident ramollissement of the posterior 
lobe of the left hemisphere, presenting nearly the same characters as that in 
the anterior lobe of the right ; the thalamus and corpus striatum of the right side 
do not present any appreciable lesion ; the thalamus of the left appears softer 
than natural, presenting numerous bloody points, or strige when cut into; 
about 5ij of serum were found at the base of the brain, which appeared to 
have escaped from the ventricles. 

Thorax. — Lungs crepitant and free, slightly engorged at the base ; they 
contain numerous tubercles in the form of granulations disseminated throughout 
their substance; trachea and bronchial tubes slightly injected. 

Ahdomea. — Liver of a pale-red colour, having lost the chocolate hue which 
is common to it in health; tissue quite firm; mucous membrane of stomach 
pale, except at the great cul-de-sac, where it is slightly injected; intestines 
moderately distended with gas ; time did not permit to examine them carefully, 
but, in cutting into the small intestine at one or two points, the mucous mem- 
brane was found to be pale, except toward the lower extremity of the ileum, 
where it was injected, and the glandulse agminatse at that point were ele- 
vated, and much reddened; the isolated follicles of the large intestine were 
very numerous and c|uite distinct, not ulcerated; the mucous membrane was 
pale; the left descending colon and the upper portion of the rectum were 
much contracted, the diameter being about sufficient to admit the little finger; 
kidneys and peritoneum healthy. Other organs not examined. 

Case II. — F. B., a female child, sst. 4 months, had a slight cough from 
birth, but with that exception her health was good until three weeks old, when 
the bowels became disordered. There was diarrhoea alternating with costive- 
ness, the stools presenting a greenish appearance ; the number of evacuations, 
however, was at no time very great ; the bowels were much distended with 
flatus, and the child seemed to be in almost constant pain; this extreme irri- 
tability indeed appeared to be the most marked feature in the case; the cries 
were almost unceasing, so that neither parents nor nurse had any rest. The 
father is now in the last stage of phthisis, and has lost three brothers and 
three sisters by the same disease. The grandfather died of cholera. The 
grandmother is still living, and enjoys excellent health. The mother of the 
child is also healthy. Five days before its death, it presented symptoms of cere- 
bral disturbance ; the limbs were slightly convulsed, but there was no vomiting. 
No screaming or unusual cry was heard, but its moans were almost constant. 

The day before its death, it had another and stronger convulsion, the left arm 
and left lower extremity alone being affected. I did not see the child during^ 
life, but made the autopsy at the request of the attending physician, from whom 
the above account of the symptoms is derived. The state of the bowels after the 
invasion of the cerebral symptoms was not noted ; it is presumed, however, they 
were costive, for diarrhoea is of very rare occurrence in tubercular meningitis; 
in all the cases observed by Drs. G-erhard and Eufz, it occurred but once, 
and was then moderate; yet we have known the last stage of cholera infantum, 
when the brain was much affected, to be mistaken for tubercular meningitis, 
although the number of stools amounted to twenty per diem ; hence the im- 
portance of attending not only to the present symptoms, but of being conver- 
sant with the natural history of disease. 

Autopsy^ January i:tli, 1839, ten hours after death. — Exterior. — Body 



( 



1850.] Hallowell on Tubercular Diseases. 25 

well developed, emaciation moderate ; no oedema of upper or lower extremities ; 
no rigidity; cervical glands enlarged, and firm to the touch. 

Head. — But little blood exterior to dura mater ; arachnoid perfectly pale 
and transparent- a considerable quantity of limpid serosity beneath; pia 
mater moderately injected, not adherent to surface, veins much distended; a 
few small granulations noticed beneath the arachnoid upon the upper and 
outer aspect of the middle lobe of the left hemisphere ; a few are also seen in 
the left fissure of Sylvius; neither the pia mater nor the arachnoid immediately 
surrounding these granulations is in the least injected; cortical substance pale 
ash colour ; rather more than a line in thickness ; convolutions not depressed, 
about seven lines in breadth; medullary substance pale, not injected; of 
natural firmness; no serosity in cavity of ventricles. Base. — Pia mater of 
base injected, but less so than upon convex surface; in the arachnoid sur- 
rounding the commissure of the optic nerves is observed a small deposit of a 
light-yellow colour, and jelly-like consistence; pons and medulla oblongata 
firm; cerebrum of remarkably good consistence. There is a considerable 
quantity of limpid serosity in the upper portion of spinal canal. Spinal mar- 
row not examined. 

Thorax. — Pleura pale and moist, not adherent in any part; beneath the 
costal portion of the right are observed a few small tubercles. Lungs pale, 
reddish anteriorly, of a deeper red posteriorly, mottled with livid. A few 
emphysematous bullae are seen along the anterior border of the upper and 
middle lobe of right lung, and of the upper lobe of left. Pulmonary pleura 
opaque in points, but not thickened ; tubercles are observed in great abund- 
ance beneath it, of the size of millet seeds, spread over the entire surface of 
the lungs, isolated for the most part, but often agglomerated, forming patches 
of a light yellovf, or straw colour. They are most numerous upon the outer 
aspect of the upper lobe of the left lung, near its inferior angle, where the 
opacity of the pleura is also greatest, A marked sensation of roughness is 
communicated to the finger on passing it over the pleural surface. Tissue of 
lungs throughout of a dull red colour, hepatized, and filled with miliary 
tubercles. When put in a basin of water, they sink to the bottom. Mucous 
membrane of trachea and bronchi pale throughout; consistence normal; 
numerous small granulations are seen immediately beneath the mucous lining 
of the smaller ramifications of the bronchi, but no trace of tuberculous matter 
can be detected upon its surface. Bronchial glands enlarged and tuberculous. 
A chain of them is observed on both sides of the left bronchus, the calibre of 
which is reduced in size by their compression ; they occupy the whole of the 
angle of bifurcation, and extend along the sides of the trachea above it about 
three quarters of an inch. None are observed on the opposite side of the 
right bronchus. The largest of these glands is about ten lines by four in size. 
They present various degrees of tuberculization; several of them are of a 
light pink colour externally, but when cut into are found to contain rounded 
yellowish masses, of a cheese-like consistence, the rest of the gland retain- 
ing its healthy appearance; others are totally changed in structure, being of 
a light yellow colour throughout, and softened in the centre; in others, 
again, the softening has proceeded further, the whole of the gland being con- 
verted into a light yellow, inodorous pus of the consistence of milk. Hearty 
circumference at base, four inches and one-eighth ; length, measured upon 
its anterior face from root of aorta, following the line of curvature, two inches ; 
in a SLi'dight line, one and a half; breadth anteriorly, following the line of 
curvature, two and a half inches ; in a straight line, one and three-quarters ; 
thickness of left ventricle, exclusive of columna) carncEe, three lines ; of right, 



26 Hallowell on Tubercular Diseases. [Jan. 

one and three-tenths. Foramen ovale not entirely closed^ an opening existing 
large enough to admit a probe. The crescentic margin and laminse are very 
thick, and overlap each other considerably, so that no communication probably 
existed between the two cavities. Weight of heart, after macerating for seve- 
ral days, nine drachms. 

Abdomen. — Lining membrane of oesophagus pale, except a space about an 
inch from cardiac orifice of stomach, where it is of a light pink colour, a 
few fine arborizations being seen upon its surface ; consistence normal, strips 
being obtained its whole length; peritoneum pale and moist; no effusion of 
serosity; intestines moderately distended; stomach of normal size, containing 
a quantity of dark-looking fluid, without perceptible odour. Mucous mem- 
brane pale throughout and apparently of healthy consistence; strips an inch 
in length are obtained at its pyloric extremity. Mucous membrane of small 
intestine pale, and of good consistence, yielding strips three or four lines in 
length; it contains a quantity of matter of a light yellow colour, of the 
consistence of gruel, tinged with a shade of green towards its inferior extremity. 
Mucous membrane of large intestine quite pale throughout; consistence 
normal, strips seven lines in length being readily obtained ; its entire surface 
is studded with mucous cryptae, containing a whitish matter, causing the in- 
testine to look as if sprinkled with grains of sand. The largest is about 
three-fourths of a line in diameter. Beneath the mucous coat, near the middle 
of the intestine, is a single tuberculous deposit; it is of a dull white colour, 
about half an inch in diameter. Mesenteric glands, with few exceptions, 
healthy; several of them are enlarged and tuberculous, presenting a yellow 
appearance when cut into, with softening in the centre. Liver of a pale 
reddish colour externally, mottled with yellow; reddish internally, not en- 
gorged; the two substances indistinct. Gall bladder moderately distended 
with a light-yellowish or straw-coloured bile, staining paper a light orange. 
Spleen of a reddish-brown colour externally, three and a half inches in length 
by one and a half in breadth ; its surface is studded with tubercles, four of 
which are much larger than the rest, and project considerably above the sur- 
rounding surface. They are about three lines in diameter, and of a light 
yellow colour, with smooth and rounded surfaces; they are softened in the 
centre, a cream-like fluid escaping on incision, having a small central cavity. 
Tissue of spleen firm, of a deep chocolate-brown colour, containing numerous 
tubercles of the size of a pin's head, and even smaller. Kidneys light brown 
externally; cortical substance pale ash colour, tissue firm. The pancreas, with 
the exception of about one-third, or that portion of it immediately in contact 
with the duodenum, is converted into an irregular mass of a light yellow^ 
colour evidently tuberculous. On cutting into it, there escaped a considera- 
ble quantity of inodorous pus, of a light yellow colour, of the consistence 
of cream. The diseased portion measured two inches in length along its 
convex margin, and one in breadth.* Bladder moderately distended ; uterus 
and appendages healthy. ^'^ 

Case III. — G-. B., set. five months, born of healthy parents, rather large 
at birth, continued perfectly well for several months; at the expiration of 
that period, she was observed to have a slight hacking cough, which dis- 
appeared in the course of three or four weeks ; when three months old, she 
had an attack of catarrh, which lasted about a month, and did not require 
any active treatment. Her present illness commenced two weeks ago ; for 

* Tubercular disease of the pancreas is exceedingly rare. Dr. Carswell states that he 
never observed it. 



1850.] Hallowell on Tubercular Diseases. 27 

some time previous, she was observed to be restless, especially at niglit, and 
would frequently scream out ; slight convulsive movements were also noticed 
in the muscles of the left side of the face. Dr. Warrington was requested to 
see her for the first time, on Monday, Aug. — , when she was in convulsions. 
The convulsions affected the face and left side of the body. She was bled 
^viij, after which the left arm became paralyzed. She vomited several times 
after taking the breast, during the first week of the attack, but not at any 
other time. The bowels, in the beginning, were rather loose; they have since 
been somewhat costive, but have been easily regulated by moderate doses of 
castor oil. Last evening, two dozen leeches were directed by Dr. W. to be 
applied to the temples and mastoid processes ; they bled freely, but did not pro- 
duce fainting. Blisters had been put behind the ears two days previously. 

Present state. — jSejJt. btli, 1840. Decubitus dorsal, face quite pale; pupils 
dilated, but contract on exposure to the light ; deviation of mouth toward 
right side ; eyes widely open ; lids equally separated; cries almost incessant; 
no alteration of voice; no stupor; deglutition easy; right arm frequently 
in motion, picking at the nose; joints of left rigid; the rigidity is most 
marked at the elbow ; imperfect paralysis of left lower extremity. Sensibility 
acute; abdomen not distended, rather tense, not painful on pressure; bowels 
open twice yesterday, once in the night ; not this morning ; skin of natural 
temperature, pulse of moderate volume, 180, not intermittent; respiration 
45, irregular; no cough; chest sounds well on percussion; respiration not 
examined. R. — Sub. mur. hydrarg. gr. iv; g. acacise pulv. gr. xii. M- ft. 
pulv. xvi. Grive one every two hours. Blisters behind the ears, to be dressed 
with mild mercurial ointment. 

Evening, 6 P. M. Cries and agitation continue ; right arm constantly in 
motion ; frequent motion also of right lower extremity ; rigidity of left elbow- 
joint i-atlier increased; no convulsive movements; pupils same as last noted; 
a rather fixed expression of countenance; temperature of skin increased since 
morning visit. Pulse 160, more full than when last noted ; respiration 60, 
irregular ; no cough ; bowels open but once since last visit ; stools dark green, 
somewhat offensive ; urine free. E. — Two cups to the back of the neck (^iss 
of blood). Continue other treatment. 

Qth, 10 J A.M. Was more quiet after the cupping, until 2 A. M. Since 
then has been restless; cries almost constantly, as if in pain; right arm con- 
tinues agitated; at times tremulous, but no convulsive movement of it; has 
moved the left arm and left lower extremity, which she has not been seen to 
do since the bleeding. Bigidity of elbow-joint greatly diminished; shoulder and 
wrist joints more supple ; pupils same as last noted. No somnolency or stupor; 
after the spells of crying, however, there is a short interval of quiet, during 
' which she appears to be in a transient dose ; these intervals are seldom of 
longer duration than one or two minutes. The eyelids are closed, and the 
right arm becomes relaxed, and falls nearly to the side of the body, if lifted 
up and suddenly let go. Skin of natural temperature, complexion sallow; 
pulse 140, volume less than at evening visit; soft, regular, not intermittent; 
respiration 42, no cough. Tongue dry, slightly coated with a yellowish fur; 
refuses the breast, which induces the mother to think that the mouth is sore ; 
but no evidence of it is observed, and there is no mercurial odour in the 
breath. Bowels open, twice since last visit ; discharges appeared somewhat 
painful ; cries when pressure is made upon the abdomen ; has taken eleven 
of the calomel powders. R. — Repeat blisters behind the ears. Calomel pow- 
ders every three hours. Evaporating lotion of spts. nitre to head. 

Itli, 7^ P.M. Has been much more quiet since last visit; screams out 



28 Hallowell on Tubercular Diseases. [Jan. 

occasionally, and then relapses into a continued doze, from which she is easily 
aroused; pupils moderately dilated, contracting slowly on exposure to light; 
slight oscillation of pupils ; when disturbed by pressure upon the abdomen, 
awakes crying ; the brows are contracted, and the nasal traits described by 
M. Jadelot are well developed. Temperature of skin increased since last 
visit; pulse 180, of moderate volume, regular, but intermittent; respiration 
very irregular, 56 per minute; coughed once or twice this morning. Chest 
sounds well on percussion; respiratory murmur not perceptibly altered; takes 
the breast well; abdomen rather tumid; cries when pressure is made upon it, 
but it is very doubtful whether that causes pain ; bowels disturbed six times 
since last visit — four times in the night, twice in the afternoon ; stools not 
painful, of a dark green colour. R. — Emplast. lyttae 2x2 to back of neck; 
gum water for drink. 

8^A, 10 A. M. Slept during the greater part of yesterday, but has been 
very restless during the night. Agitation and cries almost constant ; pupils 
moderately dilated. Slight rigidity of joints of left upper extremity; sensi- 
bility of left side somewhat impaired ; right leg almost constantly in motion ; 
pulse 168, small and regular, not intermittent; respiration irregular, 42; 
coughed two or three times this morning; cough short and dry; chest sounds 
well on percussion anteriorly ; respiration not perceptibly altered, feeble pos- 
teriorly ; no rale ; tongue dry, slightly coated with a whitish-yellow fur ; 
abdomen somewhat tense ; cries when pressure is made upon it ; bowels not 
distui^ed since last visit. % . — 01. ricini 5J ', calomel powder every four hours. 

Evening, 7. During the day, more or less agitated; afterwards, intervals 
of stupor, lasting from a few minutes to an hour or more ; no cries, but fre- 
quent moans ; slight cough (two or three times during the day) ; left upper 
extremity quite relaxed ; no rigidity perceptible ; bowels open twice since last 
visit; stools yellow, not painful; seems somewhat hoarse, and does not take 
the breast well ; abdomen supple, cries when pressure is made upon it, and 
agitates the left lower extremity; pulse 132, soft, regular, not intermittent; 
respiration irregular, 45; temperature of skin but little increased. R. — -Con- 
tinue powders. 

\Otli, 11 J A. M. Stupor interrupted by frequent moans and cries; pupils 
moderately dilated ; brows contracted during cries ; moves the right arm and 
leg less than yesterday; marked rigidity of all the joints of left upper 
extremity; rigidity also of those of lower. Pulse 150, regular, smal], not 
intermittent; respiration cjuite irregular, 45. Coughed several times this 
morning ; bowels open twice yesterday, during the day ; not since evening 
visit ; abdomen slightly tense, cries when pressure is made upon it ; deglu- 
tition much impaired, refuses now to take the breast; skin slightly warmer 
than natural; tongue rather dry, slightly coated at base; no convulsive move-/ 
ments. R. — Continue powders. 

11th. Restlessness continues, with short intervals of quiet; moans and 
cries almost constant; decubitus dorsal, with the head constantly inclined 
to the right side ; face pallid, with a marked tinge of sallowness ; neck rigid. 
In the night, convulsive movements of right arm ; the joints of this as well 
as those of the left upper and lower extremity appear rigid ; has recovered 
in a great measure the use of the left upper and lower extremity; the left 
forearm is nearly as much in motion as the right, which she moves, however, 
less often than a few days ago. Pupils very slightly, if at all, dilated ; they 
contract rather sluggishly on exposure to the light ; lids equally separated ; 
pulse 158, small and regular, rather feeble, not intermittent. Skin cool, 
temperature uniform, nostrils not dilated, respiration irregular, 48 ; has not 



1850.] Hallo well on Tubercular Diseases. 29 

been heard to cougli since last visit ) tongue moist in front, base and centre 
not observed; abdomen more tense and tumid, cries when pressure is made 
upon it. Bowels open three times since last visit ; stools green, two of them 
rather large, whether painful a matter of doubt ; draws up the limbs at times, 
and seems in pain ; blisters healed ; urine free ; has taken altogether eight 
grains of calomel. R. — Continue powders every six hours. 

18 ^A, 11 J A.M. Rigidity of neck has nearly disappeared, is now lying 
with the head inclined to the left side; lower jaw quite rigid; mouth closed; 
frequent tetanic convulsive movements of both arms, which are forcibly ex- 
tended, the fists being clenched, and the thumbs flexed in the palms of the 
hands; moves the left lower extremity. There appears to-day but little 
rigidity in the joints of this extremity; other joints more or less rigid; eye- 
bails frequently in motion, no convulsive movements of them noticed; pupils 
somewhat dilated, the left rather more than right ; the left side, however, is less 
exposed to the light, and the position was not changed ; countenance expressive 
of suffering ; frequent moans and subdued plaintive cries ; no screams ; pulse 
168 ; temperature of skin nearly natural, warmer upon abdomen ; respiration 
64; abdomen slightly tumid, not distended, cries when pressure is made 
upon it; bowels open once since last visit; stools dark coloured, not painful. 
R. — Gum water. 

H.tli. Died at 2 A. M. The muscles of the foce and upper extremities 
were much convulsed, the convulsions appearing to be of a tetanic character ; 
the eyes were turned upward, and the countenance much distorted; her screams 
were also violent ; the bowels were open twice ; the rigidity of the neck had 
disappeared before death. 

Autopsy, 14:th, 28 hou7-s after death. — Exterior. Embonpoint moderate; 
no emaciation; slight sallow tinge of skin; no rigidity; posterior parts of 
body a little mottled from position. 

Head. — Pia mater of left hemispliere moderately injected ; a very few 
minute whitish points, scarcely perceptible, observed at different points, for the 
most part along the anfractuosities or fissures between the convolutions ; one of 
these, rather larger than the rest, appears to be surrounded by a ring of vessels ; 
moderate effusion beneath arachnoid; arachnoid pale and transparent. Right 
hemisphere. — Pia mater very much injected; a considerable amount of citron- 
coloured serum beneath the arachnoid, along fissure of Sylvius; the lateral 
and inferior portions of the hemisphere are thickly studded with small, whitish 
bodies, slightly elevated, and more or less agglomerated; the injection is ob- 
served to be greatest where the tubercular deposit is most abundant; similar 
vessels are observed to radiate from the circumference of each of these groups, 
and also from the isolated tubercles themselves; the latter disposition, how- 
ever, is by no means uniform, the pia mater immediately surrounding many 
of the isolated granulations being perfectly pale. The vessels radiating from 
the larger groups inosculate with each other, forming a minute, delicate net- 
work, extending over nearly the whole surface of the hemisphere. The 
inner surface of the left hemisphere presents a large number of these granu- 
lations, following the course of the fissures, most numerous upon the inferior 
convolution, or that immediately surrounding the corpus callosum. Cerebellum 
for the most part pale; a few deposits are observed upon its surfiice, several 
of them of large size; the largest is about three-fourths of a line in 
diameter, situated upon the under portion of the cerebellum, and slightly 
elevated above the surrounding surface ; no ring of vessels is observed en- 
circling it, but a few minute radiations, scarcely perceptible, are seen 
branching from it; surrounding the commissure of the optic nerves is a con- 
No. XXXVIL— January, 1850. 3 



30 Hallowell on Tahermdar Diseases. [Jan. 

siderable yellowish amorphous deposit, a line or more in thickness. Central 
portion of the v/holo of the right hemisphere very much softened ; central 
portion of left thalamus and corpus striatum natural; surface somewhat 
softened; right thalamus rather softer than the left. A portion of the right 
corpus striatum very much softened ; the softening in the central portion of 
the right hemisphere presents a pink-coloured tinge ; a number of small ves- 
sels are observed upon it ; left hemisphere a little injected; corpus callosum 
and septum lucidum softened ; pons and medulla oblongata healthy. 

Thorax. — Lungs pale reddish anteriorly, reddish violet posteriorly ; tissue 
filled with tubercles of the size of pin^s heads and of a light yellow colour, 
more abundant in the upper lobes. Lower lobes somewhat engorged, but float 
in water. Pleurde pale ; no effusion within their cavity ; not adherent. Lining 
membrane of trachea not injected; two of the bronchial glands are slightly 
enlarged and tuberculous; the rest are healthy. Heart of normal size; 
length upon its anterior face, from origin of aorta, following line of curva- 
ture, twenty and a half lines; circumference at base three and a quarter 
inches ; wall of right ventricle one line in thickness, of left three lines ; right 
auricle distended with a fibrinous coagulum extending into the right ostium 
venosum, having its inferior extremity attached to the meshes of the tricuspid 
valve ; there is a slender coagulum also in the pulmonary artery extending 
into the right ventricle. Pericardium healthy ; valves and lining membrane 
healthy. 

Abdomen. — Peritoneum pale and moist ; no effusion within its cavity. Liver 
of a reddish-brown colour externally, both upon its upper and under surface, 
except along its inferior margin, where it is of a slate colour; a number of 
small tubercular granulations are observed upon its surface, most abundant 
upon left lobe ; they are seated immediately beneath the peritoneum, in the 
sub-peritoneal cellular tissue, and one or tv/o of the size of pins' heads are 
observed in the tissue of the gland. Measurements of liver. — Transverse 
measurement five inches ; of right lobe three inches ; length of antero-pos- 
terior diameter of right lobe three and a half inches; tissue firm. Gall 
bladder moderately distended with thin yellowish bile, staining the finger a 
bright orange. Stomach of moderate size, pale externally, its inner membrane 
coated with a thin layer of yellowish mucus, without perceptible odour. 
Mucous membrane quite pale throughout, somewhat thinner than natural; 
mucous follicles scarcely perceptible ; consistence of mucous membrane normal, 
strips seven or eight lines in length being obtained along the greater and lesser 
curvatures, and three or four in cul-de-sac. Small intestine. — The duodenum 
contains a quantity of matter of a light yellow colour, of the consistence of 
pap, assuming an orange hue at its lower portion ; in the lower part of the 
jejunum and in the ileum it is of a dark colour, almost black; at the lowerr'-.-v^^ 
part of the ileum, near its termination, it is of the colour of Indian yellow; 
mucous membrane thinner than natural, yielding strips from one to two lines 
in length not apparently softened ; mucous crypts indistinct ; one or two small 
tubercular deposits are observed in the ileum, and in one of the glands of 
Peyer there is an ulceration two lines in length by one and a half in breadth ; 
the ileum contains a quantity of fluid feces in its upper half of a dark green 
colour; the lower half is somewhat contracted, and nearly empty; lining mem- 
brane pale. The iarge intestine yields strips of the same length as the small; 
crypts distinct, but not remarkably developed. Spleen two inches in length 
by one and a quarter in breadth, of a reddish-brown colour externally, filled 
with tubercles. Left Iddney two inches long by one and a quarter in size, of 
a pale-red colour externally ; several minute tubercular deposits are observed 
in its cortical substance. Riglit kidney two inches in length by one and a 

r 



1850.] Hallowell on Tiibercular Diseases. 31 

quarter in breadth, presenting tlie same general appearance as left; no 
tubercles. Pancreas healthy. Mesenteric glands enlarged, the largest about 
eight lines by six in size, of a pale whitish colour ; tissue firm. Bladder 
empty; mucous membrane pale. 

Case TV. — Henry W., set. six months, had good health until eight weeks 
ago, when he was attacked with cough, which came on without any appreci- 
able cause, and lasted six weeks. The precise character of the cough could 
not be ascertained; it did not, however, appear to require medical treatment. 
On Wednesday, the 3d of September, he was obseryed to be very fretful, and 
was supposed to have some pain in the bowels, for which he took a dose of 
castor oil. On the Thursday following, there was observed some twitching of 
the balls of the eyes, which were turned inward, and slight convulsive move- 
ments of the arms were noticed. The same day the right arm and leg were 
observed to be paralyzed, since which he has not been seen to move either. 
Vomiting occurred for the first time, on Friday, and lasted three days. It 
occurred more frequently on the first of these than on the two succeeding ; 
bowels regular. The mother of the child is phthisical; the father enjoys 
good health. 

Treatment. — Two cups to back of neck, and one-sixth of a grain of calomel 
every three hours. 

Sept. lOtJi, 1840; — In consultation with Dr. Warrington. Expression 
of countenance lively, but somewhat vacant; smiles, and seems to be per- 
fectly free from pain; is sitting upon its mother's lap; face pale; con- 
junctiva bright; at times a little fretful; pupils natural; right upper and 
lower extremity paralyzed; no rigidity; left not more in motion than usual; 
deglutition easy; tongue natural; bowels disturbed by calomel powders; stools 
dark green, and somewhat oiFensive; not painful; abdomen supple; no pain 
on pressure; temperature of skin natural; pulse 144, soft and regular; respi- 
ration natural; chest sounds well on percussion throughout; no marked alter- 
ation of respiratory murmur; no cough. R. — Continue calomel powders. 

14:th. Same state. — Bowels regular; pulse soft, regular, 120; appetite 
good. Abdomen distended, quite tumid, not painful on pressure. 

Oct. 10th. Called to-day, with Dr. Warrington, to see the child. Since last 
note, there has been but little change in the symptoms, except that, within four 
or five days past, it has been very irritable, crying and fretting almost con- 
stantly. About two days ago, there was slight vomiting, which did not return 
until the evening of the day before yesterday, when he vomited once rather 
copiously; bowels regular, open once daily; stools rather large, dark coloured, 
quite oiFensive; the mother thinks they are voided with some pain. Within 
the last two weeks, there is marked emaciation, which appears to be progress- 
ing. Present state. — Appears quite fretful, having just awaked from a sleep of 
half an hour's duration. Face quite pale; eyes dull, and with but little ex- 
pression; pupils not evidently dilated; forehead wrinkled; nasal and genai 
traits well marked; motion of right upper and lower extremity imperfect, 
perhaps rather increased since last note; moves the foot and hand, but cannot 
elevate the latter as high as the forehead. Skin very little warmer than 
natural; no cough (mother's statement); has had none for two weeks past; 
appetite good, takes the breast well; pulse, when asleep, 104; respiration 
slightly accelerated. Chest on left side resonant, both anteriorly and pos- 
teriorly ; on right, resonance impaired throughout, with feeble respiration, and 
marked resonance of the voice; abdomen slightly resisting, not painful on 
pressure; tongue dry, coated with a thin whitish fur; gums not swollen. 



32 Hallowell on Tubercular Diseases. [Jan. 

B. — Sub. mur. liydrarg., pulv. opii et ipecac.^ aa gr. vi; Gr. acaciae pulv. gr. 
xii. Div. in pil. xxiv. Sig. Three to be taken daily. 

13^/l Has had convulsions during the last two days^ they were first ob- 
served on Sunday morning, 11th; the head was drawn backward^ and the 
hands clenched; slight convulsive movements of the face were also observed; 
the convulsions returned frequently during Sunday and the day following, but 
have not been observed this morning. The bowels were open three times 
yesterday, and four times during the night. Stools large, of a dark greenish 
colour, and quite offensive, not evidently painful; is now lying upou the 
mother's lap; decubitus dorsal; face quite pale; no wrinkles upon face or 
forehead; expression quite calm; lids half closed, opens them wide occasion- 
ally, with a languid expression ; forehead and temples warm ; cheeks cool ; 
temperature of skin generally but little elevated; pulse 145, regular, not in- 
termittent; respiration 40. No cough; bowels not painful on pressure; 
motion of upper and lower extremity of right side same as last noted ; rigidity 
of right elbow and shoulder joint; slight rigidity of wrist; joints of lower 
extremity supple; sensibility in paralyzed limbs acute. Chest. Dulness on 
percussion under right clavicle; the dulness below this point not marked; 
the respiration is rude, however, over both sides of the chest in front; most 
distinctly on right below the clavicle; posteriorly resonance impaired on right 
side, with marked resonance of the voice and rudeness of respiration; on the 
left, it is more expansive, but is somewhat altered in character; no rale; re- 
fused the breast yesterday^ but takes it to-day. R . — Emplast. lyttae behind 
the ears; omit powders. 

14iA. Slight twitching, this morning, of the muscles of the face and hands. 
No convulsions, no strabismus ; is more disposed to sleep ; was quiet in the 
night, until three o'clock, when he became restless and fretful; took one of 
the powders of cal. opium and ipecac, after which he became more com- 
posed ; sleep for the most part calm ; at times a slight frown, and occasional 
twitching of the muscles; respiration irregular, at present 40, at times sighing; 
frequent motion of under jaw, as if chewing; nostrils slightly in motion; 
face quite pale; skin slightly warmer than natural, pulse more frequent, 155, 
regular, not intermittent; abdomen not distended, not painful on pressure; 
no cough; bowels disturbed five times since last visit, three times before taking 
powders; stools same as last noted, not painful; sense of hearing nearly gone; 
sees well, but does not take particular notice of any object. 

\4:tli. Frequent convulsive movements of muscles of face and ujjper ex- 
tremities; strabismus; balls of eyes in constant motion; conjunctiva some- 
what suffused; marked rigidity of right shoulder and elbow-joint; wrist less 
rigid; joints of opposite extremity supple; joints of both lower extremities 
supple; pupils much dilated ; the sight, however, is not destroyed. On placing 
the fingers near the lids, they are repeatedly closed ; sensibility of paralyzed 
limbs acute; deglutition easy; more quiet, but is easily disturbed; pressure 
upon abdomen productive of uneasiness, arising probably from general irri- 
tability; bowels disturbed four times since last visit; appearance of stools 
same as last noted, not painful; pulse more frequent, 160, of moderate volume, 
regular, not intermittent; respiration irregular, more slow, 32; no cough. 
Temperature of skin same as last observed; the blisters have nearly healed. 
Has taken no medicine since last visit. R . — Re-apply the blistering ointment. 

Ibtli. Was quiet during greater part of yesterday; restless in the night. 
At half past ten this morning took a powder, since then has been greatly 
agitated; limbs and body in almost constant motion; frequent motion of 
head from right to left ; features slightly distorted ; mouth drawn to the left 



1850.] Hallowell on Tuhercular Diseases. 33 

side; strabismus; at times, convulsive movements of the upper extremities; 
hands clenched; lips slightly livid; pupils contracted, sight gone. On placing 
the fingers before the eyes, no impression is produced upon the lids. Respi- 
ration laboured, irregular, 60 per minute; no cough Upper and back part of 
head quite warm, forehead and temples moist; hands cold; abdomen very 
warm; temperature of lower extremities natural; pulse imperceptible at the 
wrist; no vomiting. Bowels open three times since last visit; stools same 
appearance and colour as last noted, not painful; sonorous rale over whole 
of chest, both anteriorly and posteriorly; marked dulness on right side pos- 
teriorly and under right clavicle. B. — Oxycrate to head; garlic poultices to 
wrists and ankles; enema of castor oil. 

IQth. Died at 4 P. M. 

Autopsy J Oct. 17 th, twenty-three hours after death. — Exterior. — Body well 
developed, very slightly emaciated; slight rigidity of lower extremities; 
none of upper surface pale ; no oedema ; posterior parts of body mottled from 
position. 

Head. — An unusual quantity of blood on separation of scalp ; arachnoid 
pale and moist ; no effusion beneath ; pia mater not injected ; veins moderately 
distended. On examining the brain, both upon its upper and under surface, 
with care, a few minute whitish points are observed in the course of the an- 
fractuosities ; they are perfectly distinct, but, from the smallness of their size, 
might readily pass unobserved by one unacquainted with the anatomical 
character of this form of tubercular deposit in its early stage. Cortical substance 
pale ash colour; medullary substance of left hemisphere softened throughout ; 
it is perfectly white in its appearance, no trace of vessels being observed 
in it, resembling very much the white of an egg beat up, except that its con- 
sistence is somewhat greater; the cortical substance is also softened, but much 
less than the softer portions of the medullary. Cortical and medullary por- 
t ions of right hemisphere of natural firmness, except in the posterior lobe and 
a small portion of the anterior, which are both softened. Corpus callosum, 
septum lucidum, and fornix much softened. Left thalamus and corpus stri- 
atum softened; right normal. Upon the surface of the left ventricle are ob- 
served a number of yellowish deposits, similar in appearance to those upon 
the base of the brain. The ventricles contain about one ounce of citron- 
coloured serum; and an unusually large quantity, at least giv, escaped rrom 
the base of the brain ; a large quantity was also observed in the upper por- 
tion of the spinal canal. Cerebellum pale externally, of normal consistence ; 
right lobe perhaps a little softened. Immediately posterior to the chiasm of 
the optic nerves, in the space included between it and the anterior margin of 
the pons, is a large deposit of yellowish amorphous matter, nearly a line in 
thickness ; it oficrs a certain resistance to the finger, and cuts with moderate 
firmness under the knife. Pons and medulla oblongata healthy. 

Neck. — Larynx pale and moist ; cervical glands not examined. 

Thorax. — Left lung fawn colour anteriorly, reddish posteriorly, except 
about two-thirds of the posterior surface of the lower lobe, which is of a dark 
violet colour, and offers a greater degree of resistance to the touch than the 
rest of this lobe. Pleura free ; no serosity within its cavity ; immediately 
beneath it, over the whole surface of the lung, are numerous semi-transparent 
bodies, of a light yellow colour, about the size of pins' heads ; several of them 
are opaque in the centre. Tissue of upper lobe pale reddish, imperfectly 
crepitant, filled with granulations of the size of millet seed, more or less 
opaque, of a whitish-yellow colour. Lower lobe hepatized in about two-thirds 
of its extent, presenting a smooth surface on incision. Tissue firm, a mode- 



34 Hallowell on Tubercular Diseases. [Jan. 

rate quantity of blood exuding from it on pressure ; the rest of this lobe 
resembles the upper in colour, and is also crepitant to a certain extent. Nume- 
rous miliary granulations are scattered throughout it. Right lung pale ante- 
riorly, reddish violet posteriorly ; the upper lobe presents the same appear- 
ance, when cut into, as the corresponding lobe of the opposite side, except that 
the tubercles are more numerous and of larger size. The whole of the inner 
aspect of this lung, with the exception of a space along its anterior border, 
about half an inch in extent, is of a violet colour, extending over nearly the 
whole of the middle and lower lobes, and a small part of the upper. On 
cutting into the dark-coloured patches, the tissue of the lung is found to 
be hepatized, the hepatization extending to within about four lines of the 
exterior surface of the lung. The whole of the lung is studded with granu- 
lations, more or less opaque, presenting the same appearance as those of the 
opposite lung. In the posterior part of the lower lobe, near its inferior mar- 
gin, is a tuberculous deposit of a light-yellow colour, two lines and a half iu 
diameter, somewhat softened in the centre. The unhepatized portions are 
more dense than natural from the presence of the tuberculous bodies within 
them, but float in water. Bronchial glands greatly enlarged ; one of them, 
situated at the bifurcation of the trachea, is nine lines by five in size, and of 
a pale-reddish colour externally, marbled with yellow. Tissue pale, firmer 
than natural, presenting several nodules of tuberculous matter — one of them 
five lines in length, by three and a half in breadth, of a yellowish-green 
colour, more or less softened in the centre. On the right of the trachea and 
somewhat in front of it, occupying a portion of the space between it and the 
upper lobe of the right lung, in contact with the thymus gland inferiorly, is 
another gland, very much enlarged ; it is sixteen lines in length by ten in 
breadth ; it is of a whitish-yellow colour internally, and of cheesy consistence, 
presenting a slight softening near its centre. Mucous membrane of trachea 
and bronchial tubes injected (examined on the 18th, 3 P. M.), the injection of 
the right extending to the smaller ramifications. Thymus normal. Heart. — ' 
Pericardium pale, containing a few drops of citron-coloured serum ; a mode- 
rate quantity of fat at base of heart, and near its apex ; left ventricle three 
and a half lines in thickness, exclusive of columnge carneas; right, a line. A 
fibrinous coagulum extends from the right auricle into the corresponding 
ventricle, and is attached by its lower extremity to the chordaa tendineae. A 
moderate quantity of dark-coloured blood in the right ventricle adhering to 
the coagulum, which extends an inch and a half within the vena cava ; little 
or no blood in right ventricle ; none in left ; a small blackish coagulum in 
left auricle, partly fibrinous, not extending into the ventricle. Endocardium 
pale, not thickened ; oesophagus pale and moist. 

Abdomen. — Peritoneum pale and moist • no eff'usion within its cavity. Liver 
of a reddish-violet colour, mottled with yellow both upon its upper and under 
surface. Both are studded with numerous whitish points, more abundantly 
upon greater lobe ; examined with a magnifying glass, they are seen to pro- 
ject but slightly above the surrounding peritoneal surface, which is perfectly 
smooth to the touch. On cutting into the liver, they are observed very dis- 
tinctly, immediately beneath the peritoneal coat, which is seen to pass over 
them. They are semi-transparent, of a whitish-yellow colour, the latter pre- 
dominating, having precisely the same appearance as those observed in the 
upper lobes of the lungs ; several are observed in the substance of the liver, 
which is of a reddish colour mottled with yellow, the two substances appearing 
distinct. Gall bladder moderately distended with thin bile, staining the finger 
Indian yellow. Stomach pale externally, containing a moderate quantity of 



1850.] Hallowell on Tubercular Diseases. 35 

fluid of a dark colour, of the consistence of gruel, without perceptible odour. 
Mucous membrane pale throughout, and apparently of normal consistence. 
Strips seven lines in length obtained from the lesser and greater curvatures, 
and three lines in length from the great cul-de-sac. The mucous membrane 
is strongly adherent to the subjacent coat, and in the great tuberosity is evi- 
dently thinner than natural ; the thinning appears to extend to all the coats. 
Mucous follicles quite distinct. The small intestine contains a quantity of 
thin, orange-coloured matter, most abundant in the duodenum and lower 
portion of the ileum. Mucous membrane not injected, stained more or less 
by the contents of the bowel. It appears somewhat softened, strips of not 
more than a line in length being obtained. Mucous follicles but little 
apparent. 

Case V. — M. J. S., set. three years, enjoyed good health, until two months 
ago, when she was attacked with cough, without any assignable cause. She 
has never had measles, or any other exanthematous disease. Her appearance 
from birth has been delicate, and she has had occasionally a slight cough scarcely 
perceptible. There has been no diarrhoea during her present illness; the 
bowels, on the contrary, being rather confined. Her physician, supposing she 
had worms, gave her a large dose of spigelia, which was followed by the dis- 
charge of a single lumbricus. She took also a mixture of assafetida, and 
some pills of hyoscyamus, containing half a grain of the extract, every two 
hours. ■ The pulse was frequent, the skin warm, and there was very great 
irritability of temper. She would hardly allow herself to be touched. The 
following powders were directed : R. — Sub. mur. hydrarg. gr. vi; pulv. 
ipecac, gr. iij ; g. acaci^e pulv. gr. xii. M. ft. pulv. xii. Sig. One every three 
hours. 01. ricini 3ij' 

The following day she was much better; she slept well during the 
night, the fretfuiness had in a great measure disappeared, and the fever was 
much diminished. I did not see her again until Feb. 1st, 1841, 11 A. M., 
when she presented the following symptoms : Decubitus dorsal, inclined to 
sleep (has a hop pillow under the head) ; easily roused, and then seems irri- 
table. Will not protrude her tongue when desired to do so. Face pale, not 
flushed ; contraction of the brows when disturbed ; nasal trait well marked ; 
great emaciation ; lips dry, encrusted ; temperature of skin but little elevated ; 
pulse 120, of moderate volume. Kespiration 41; cough short, rare, rather 
loose ; chest sounds well on percussion posteriorly ; mucous and sibilant rales 
heard on both sides; respiration rude over the whole of the chest. Abdomen 
distended ; cries when pressure is made upon it, but more from fretfuiness 
1^^^^^^^^ than pain. Bowels disturbed in the night ; stools' brownish, small, not pain- 

2c?, 2 J P.M. Emaciation progressing; much irritability of temper; in 
the night was affected, according to statement of the mother, with an in- 
ward spasm, which lasted several minutes ; face quite pale and emaciated ; 
intelligence good ; replies rational ; at times, slight vacancy of expression, 
the pupils appearing a little dilated; skin warm and dry; pulse small and 
frequent, 140 ; respiration more accelerated, 52 ; cough short but loose, rare ; 
chest sounds well on percussion ; mucous and sibilant rale in points ; the 
respiration appears more harsh and less expansive than natural. No reson- 
ance of the voice ; tongue dry and coated at base ; no vomiting or sickness of 
stomach; abdomen distended; cries when pressure is made upon it, but not 
more than when made upon other parts of the body. Bowels open twice in 
the evening; stools yellowish, not painful. R. — Pulv. ipecac, gr. iij; fol. 
digital, purp. gr. j ; g. acacijB pulv. gr. xii. Sig. One every three hours. 



\ 



36 Hallo well on Tubercular Diseases. [Jan. 

3(i, 2 J P M. Dying. Since five o'clock this morning, the respiration has 
been greatly embarrassed, and there have been slight convulsive movements; 
countenance livid; lips purple; respiration greatly accelerated, 70 per minute; 
pulse frequent, small, and irregular, 165; cheeks quite cool; slight warmth 
about head and extremities; pupils rather contracted than dilated; bowels 
open twice in the night, without pain. Died at 7 P. M. 

Autops^j, ^th, 9 A. M. Weather cold and dry. Exterior. — Emaciation 
well marked; eyes sunken; lips livid; slight lividity of neck and abdomen; 
posterior parts of body livid from position ; extreijiities rigid ; no oedema ; 
cervical glands not enlarged. 

Head. — -But little blood exterior to dura mater ; longitudinal sinus filled 
with dark-coloured blood in a semi-liquid state. Veins of pia mater mode- 
rately distended; arachnoid pale, moist, transparent; slight effusion of citron- 
coloured serum beneath. Pia mater not injected upon the convex surface of 
the brain. Upon the surface of the anterior lobe of left hemisphere, and 
upon its inner aspect, beneath the arachnoid, are several small whitish deposits 
of the size of millet seed ; two or three smaller ones are observed upon the 
surface of the right hemisphere, and one or two at the base of the brain. 
The membranes of the brain are slightly injected; cortical substance of a 
pale ash colour. Medullary pale, and of good consistence ; surfaces of ventri- 
cles moist, containing a few drops of serum; thalami nerv. optic, pons, and 
corpora striata normal ; about half an ounce of serosity at base of brain. 

N'eck. — Lining membrane of larynx pale, not ulcerated. Pharynx, tonsils, 
and uvula not examined. 

T/iorax. — Pleuras pale and moist ; not adherent ; no effusion v/ithin their 
cavities. Left lung rosy fawn colour anteriorly, except along the inferior border 
of the upper lobe, in a space two inches in extent, where it is violet. Upper 
lobe fawn colour posteriorly, lower of a deep violet. No false membrane, or 
exudation of lymph upon surface of pleura. Lobes free ; tissue of both lobes 
filled with tubercles about a line in diameter in the upper lobe, opaque, and 
of a light-yellow colour; about the size of pins' heads in the lower. In the 
upper part of the superior lobe is a nucleus of hepatization, commencing 
about an inch from the summit of the lung, and extending along the inferior 
margin in the extent above described. The rest of this lobe, as well as the 
anterior half of the lower lobe, is of a reddish-fawn colour ; the remaining 
half is in a state of hepatization, presenting a smooth or slightly granulated 
surface. A small portion cut from it sinks in water. Eight lung. — Upper 
and middle lobe of a rosy fawn colour, marbled in one or two points with 
violet. A small portion of the middle lobe near its centre is Kepatized, and 
there is also a small spot along the posterior border of the upper. Lower lobe 
fawn colour anteriorly, violet posteriorly. It is hepatized along its posterior 
border, the hepatized portion extending about an inch within the substance of 
the lung ; the whole of the lung is filled with tubercles of nearly the same 
size throughout. Lining membrane of trachea and bronchial tubes reddened, 
but not thickened. Bronchial glands enlarged and tuberculous, the largest 
about six lines in length by four in breadth. Ileart. — Pericardium pale, no 
serosity within its cavity. Several tuberculous granulations are observed 
beneath the cardiac portion of the pericardium, about the size of pins' heads ; 
one of them is situated posteriorly near the base of the auricles, the others 
are upon the anterior face of the heart. Circumference of heart at base five 
inches one-eighth. Left ventricle four lines in thickness. Left auricle partly 
filled with coagulated blood ; right ventricle a line and a quarter in thick- 
ness ; cavity empty. Some dark-coloured blood in right auricle ; valves and 
lining membrane healthy. 



1850.] Hallowell on Tuhercular Diseases. 37 

Ahdomen. — Peritoneum pale, no fluid within its cavity ; no tubercles. Liver 
six and a half inches in breadth by five and a quarter in length (in a straight 
line), breadth of right lobe four and a half inches (Fr.), depth one inch and 
three-quarters ; colour yellowish^ marbled with violet above, yellowish beneath ; 
tissue brownish red, two substances very distinct. The upper and lower 
surfaces of the liver are studded with granulations, the largest of which is a 
line or more in diameter. A solitary tubercle is found in the tissue of the 
gland, about the size of a pin's head. Gall hiadder distended with dark- 
coloured bile, staining paper a bright orange. Spleen three and a half inches 
in length (^Eng.) by two and a quarter in breadth, of a brownish-red colour, 
filled with miliary tubercles, the greater part of which are softened in the 
centre. The stomach contains a moderate quantity of mucus of the consist- 
ence of gruel. Mucous membrane pale, and of good consistence throughout — 
strips about an inch in length being obtained along the lesser curvature, 
six lines in the greater, and four lines in the great cul-de-sac. Follicles 
scai'cely visible. The small intestine contains a quantity of matter of a bright 
orange colour in the duodenum, tinged vntli green in the ileum, except at its 
lower portion, where it is of a dirty yellow ; five intussusceptions are observed in 
different parts of the intestine ; the first is situated about four and a half feet 
from commencement of duodenum ; the last is within three feet of the large 
intestine. Mucous membrane tinged with the contents of the bowel, but 
not injected, except at the lower extremity of the ileum, where it is minutely 
so, in a space about three inches in extent. Mucous cryptae quite distinct at the 
upper extremity of the duodenum, where they are about a fourth of a line in 
diameter. Consistence of mucous membrane normal, perhaps a little softened ; 
strips four lines in length in duodenum, and same in ileum ; five lumbrici, 
one of them quite large in the lower portion of the ileum. Several tubercu- 
lous granulations are noticed beneath the mucous membrane of the ileum, 
and two of the plaques of Peyer are ulcerated ; the ulcerations are each about 
a line in diameter, with elevated reddened edges. The submucous tissue, 
as well as the surrounding membrane, appears much injected. The large intes- 
tine contains a quantity of jelly-like mucus, of a grayish colour. Mucous 
membrane pale, and of normal consistence, yielding strips from five to six 
lines in length. Mucous cryptse quite distinct, about half a line in diameter. 
Mesenteric glands enlarged and tuberculous ; the tubercles are small for the 
most part, and situated near the circumference of the gland ; many of them 
are softened in the centre. Kidneys three and a quarter inches in length by 
one and a quarter in breadth ; brownish red externally. Cortical substance 
pale ; tubular portion of left, of a deep violet colour, more or less engorged. 
A number of granulations are observed in the cortical substance of both 
kidneys. Bladder distended with urine of a light yellow colour. Uterus and 
its appendages healthy. 

Case YI. — W. L., set. four months, had good health from birth until the 
26th of February, when he was attacked with influenza, then prevailing in 
town to a great extent. His father died a few days before of phthisis. The 
cough was slight, and there was but little febrile disturbance. He was directed 
some powders of ipecacuanha, followed by a dose of castor oil, which consti- 
tuted the whole treatment. On the 10th of March, he was vaccinated; three 
or four days after the vaccination, he was observed to have some fever, which, 
although slight, was perceptible up to the time of his present illness. On 
Saturday, March 27th, he was observed to be restless; on the same day, a 
slight trembling of the upper and lower extremities of the left side was no- 



38 Hallowell on Tubercular Diseases. [Jan. 

ticed. On the following day^ lie was attacked with vomiting, the fluid vomited 
having the appearance of curdled milk. On Saturday night, he was heard 
to scream out violently. These attacks were repeated the next day, but did 
not occur afterv/ard. The mother, who is robust and apparently healthy, states 
that, previous to the attack of influenza, he had no cough whatever. 

Apinl 1st, 1841. — Irritable and restless; expression of countenance pecu- 
liar, look fixed, devoid of intelligence. Strabismus, both eyes being turned 
toward the left. Slight convulsive movements of left upper and lower 
extremity; pupils not dilated; brows contracted, nasal and genal traits 
marked; no alteration of cry; skin pale, quite cool; pulse 120, regular; a 
slight, short, and loose cough. Chest sounds well on percussion ; respiration 
not carefully examined (the child is too restless); tongue moist, slightly 
coated with a thin v>^hitish fur; takes the breast well. Bowels disturbed ten 
or twelve times within the last twenty-four hours; stools green, slimy, and 
painful, not bloody; abdomen not painful on pressure. R. — Sub. mur. hy- 
drarg. gr. j ; pulv. ipecac, gr. ss. ; g. acacige pulv. gr. x. M. ft. pulv. xii. 
Sig. One every two hours. Mustard foot bath at night. Cold applications 
(vinegar and water) to head. 

4/A. No note has been made of the symptoms since last visit; the loose- 
ness of the bowels has been checked since the administration of the powders. 
The day before yesterday, they were disturbed but four times, and but twice 
within the last twenty-four hours. The stools, until this morning, were of a 
dark green colour, and appeared to be voided with pain. In the afternoon of 
the 20th, he vomited twice ; the fluid vomited was white and curdled, resembling 
sour milk. The vomiting occurred again on the following day, and was re- 
peated three times. Yesterday morning, he was observed to be more drowsy 
than before, lying almost constantly in a state of stupor. The night previous, 
he was somewhat restless ; but there were no screams, nor have there been 
since. jSFo return of convulsive movements of the limbs, but occasional 
twitching of the balls of the eyes. 

Present state, 11 A. M. Decubitus dorsal, face pale, expression of counte- 
nance quite placid while asleep ; on being disturbed, however, there is much 
knitting of the brows, and the genal and nasal traits become strongly marked. 
There is also a fixed expression of the countenance, altogether remarkable. 
Once, and that only for a moment, did the expression of the eyes appear to 
indicate consciousness of the presence of surrounding objects. G-reat rigidity 
of the neck, the head being drawn to one side, the chin approaching the right 
shoulder. Any attempts made to rotate the head, so as to return it to its 
usual position, are evidently productive of pain. No screams, but frequent 
moans ; cry natural, rather feeble. No return of convulsive movements, or 
marked rigidity of the limbs; temperature of skin natural; abdom.en moist; 
had some fever in the night ; pulse 110, of moderate volume, soft and regular; 
respiration 24; cough slight (but once or twice this morning). Chest sounds 
well on percussion throughout ; respiration free, perhaps somewhat less ex- 
pansive than natural, having some degree of rudeness; no rale. Vomited 
once this morning, soon after taking breast. Appetite good, tongue rather 
dry, coated at base and centre with a very thin whitish fur. Bowels open 
but twice within the last twenty-four hours ; stools yellowish, not slimy or 
bloody, whether painful is not remembered by the mother. R . — Two scarified 
cups to back of neck. R. — Sub. mur. hydrarg, gr. ij ; g. acacias pulv. gr. x. 
M. ft. pulv. xii. Sig. One every two hours. 

April 6th. Condition about the same. Eyes wide open, bright, look fixed ; 
no dilatation of pupils, which contract slowly on exposure to light. Was quiet 



1850.] Hallowell on Tubercular Diseases. 39 

in the early part of the nighty more restless afterward ; some twitching of 
left upper and lower extremity ; sensibility rather increased ; strabismus, both 
eyes being turned to the left ; no screams ; little or no cough ; respiration 
30. Physical signs same as last observed; skin cool; pulse 130, regular, not 
intermittent. Vomited three times since last visit, twice after taking a powder, 
and once afterward. The fluid vomited the first two times resembled curdled 
milk, the last looked like water, with whitish flakes floating in it. Bowels 
disturbed twice this morning ; stools yellowish, whether painful a matter of 
doubt. R. — Emplast. vesicat. No. 2, one behind each ear. Omit the powders 
(of which he has taken but three). 

Qth. Slight apparent amendment; lies perfectly quiet, eyes more bright, 
open. Decubitus dorsal, with face to right side ; pupils not dilated, contract- 
ing feebly on exposure to a stronger light. No screams or moans ; features 
placid ; face quite pale. The mother states that she observed yesterday a flush 
upon the left cheek. The twitching of the eyeballs continues, and occurs 
every few minutes. Left arm and leg less in motion ; convulsive movements 
(twitchings) less frequent ; sensibility same ; has not coughed since last visit. 
Respiration same as last noted. Skin cool; pulse 110, soft and regular, not 
intermittent. Vomited once, rather profusely, after taking the breast. Bowels 
disturbed but once, stools large, yellowish ; with slight admixture of green, 
the yellow more or less curdled ; whether painful, a subject of doubt. Has 
had but one of the blisters applied (behind the left ear). R. — Ung. hydrarg., 
cerat. simp., aa gj. M. ft. ung. To be applied to blistered surface. B. — OL 
ricini Jiss. 

Itli. Much as yesterday. Twitching of the balls continues; some twitch- 
ing also of the muscles of the left cheek (observed by the mother) ; the angle 
of the mouth was also drawn to the left. Left arm and lower extremity in 
motion, at times convulsed; does not appear to use the right extremity; 
sensibility on left side rather increased ; no rigidity ; no screams or moans ; 
occasional cries during spasms. Deglutition easy; skin cool; pulse 120, soft 
and regular, not intermittent. Respiration 26 ; has coughed several times 
this morning. No vomiting; bowels disturbed but once. R . — Mustard poultices 
to feet. 

%th. Eather less rigidity of neck; can lie with the head turned toward the 
right side. Eyes open and bright. Yesterday, had three strong convulsions 
within an hour, afiecting the left upper and lower extremity. There were 
also some convulsive movements of the muscles of left cheek, and also of the 
right lower extremity (statement of nurse). No screams ; moans occasion- 
ally. Any attempt to turn the neck to the left is productive of great pain. 
No cough; respiration 30, sighing; skin cool; pulse 130. Vomited after 
taking half of one of the powders last directed. Bowels open twice this 
morning; stools thin, slimy, and yellowish, somewhat curdled, painful. R. — ■ 
Emplast. vesicat. behind right ear. 01. ricini 5iss. 

9^/i. Decubitus dorsal, face inclined to right side ; lying in a state of appa- 
rent stupor. Pupils not dilated, contractile. It is doubtful whether the child 
is able to see, probably not ; it opens the eyes occasionally, but does not appear 
to notice surrounding objects. Strong convulsive movements in the afternoon, 
afiecting chiefly the left upper and lower extremity, and the left side of the 
face ; they continued at intervals during the night. No rigidity of limbs ; 
skin cool, pulse rather more frequent, 133, of moderate volume, regular, not 
intermittent. Bespiration 28. Coughed several times in the night, and once 
or twice this morning; cough short and dry. No vomiting; bowels open 
twice since last visit ; stools c[uite large, yellowish, and slimy, not curdled or 



\ 



40 ^ Hallo well on Tubercular Diseases. [Jan. 

bloody ; tlie mother thinks they give him pain. Abdomen supple ; cries when 
pressure is made upon it. R. — No medicine. Blistered surface dressed as 
before. 

l^tli, 11 A. M. Strong convulsions yesterday afternoon, affecting the whole 
body, the left side more than the right; is now lying in a state of stupor; 
decubitus on the left side, the head drawn backward. No distortion of 
features ; pupils not dilated, contracting very slowly on exposure to the light. 
Cries when disturbed by pressure made on the spine, and back of the neck, 
or sides of thorax. The upper extremities and the left lower appear more or 
less rigid, the rigidity affecting all the joints, more perceptible about the elbow 
and shoulders than at the wrists. Sensibility on both sides acute, more so on 
left. Skin of natural temperature ; pulse 130, of moderate volume, soft and 
compressible, regular, not intermittent. Respiration 28; no cough; respira- 
tion free over whole of chest, perhaps somewhat ruder than natural. No 
dulness on percussion. Abdomen supple; urine free. R. — Mustard cata- 
plasms between shoulders ; garlic poultices to feet and ankles ; enema of salt 
and water. 

lltli, 12 J A M. Had several convulsions this morning; none yesterday, 
decubitus dorsal, inclined to left side, the head still drawn backward, the 
body being more or less thrown forward ; left lower extremity much in motion. 
Great rigidity of left upper extremity, wliich is forcibly extended along the 
side of the body, the forearm and hand being in a state of semi-pronation, 
and the fingers clenched; the right is also rigid. Eyes wide open, bright, 
pupils not dilated, contracting on exposure to the light ; look fixed ; at times, 
twitching of the balls ; no cries or moans ; deglutition somewhat impaired. 
Vomited once this morning; refuses to take the breast. Skin of natural tem- 
perature, rather warmer upon head. Pulse more frequent, 145, small and 
contracted, difficult to count from the rigidity of the muscles, not intermittent ; 
respiration slow, 22, interrupted at times by a deeply-drawn sigh. Yesterday, 
for the first time, several large erythematous blotches were noticed upon the 
thorax, and'upon the left arm. These have now disappeared; but one, about 
the size of a sixpence, may be seen upon the right cheek, near the inferior 
margin of the lower jaw, and another upon the opposite side, in the same 
situation. Bowels disturbed once by injection; stools large, of a greenish 
colour, slimy. Abdomen supple, not painful on pressure. R. — Mustard 
pediluvium ; mustard sinapisms to thorax and abdomen. Enema of salt and 
water. The following liniment to the spine. R. — 01. olivar. 5iss; ol. suc- 
cin.5j. 

12^/i. Died to-day at 1 P. M. There was a return of the convulsions, which 
lasted the whole night. They appeared to be of a tetanic character, the body 
being arched forward, the head and heels approaching each other. The 
rigidity of the neck had disappeared a short time before death, so that the 
head could readily be turned from one side to the other. Considerable fever 
during the night ; no vomiting ; bowels not disturbed. Had not taken the 
breast since last visit. 

Autopsy, l^th, 9 A. M. Weather cold and moist. Present, Dr. Ashmead 
and the writer. 

Exterior. — No emaciation ; slight rigidity of lower limbs ; none of upper. 
No rigidity of neck ; no oedema ; posterior parts of body mottled from posi- 
tion. 

Head. — Surface of brain pale ; veins of pia mater but moderately distended ; 
no sub-arachnoid effusion ; numerous small opaque granulations along the an- 
fractuositieS; following the course of the vessels. They exist also upon the 



1850.] Hallowell on Tiibercular Diseases. 41 

inner aspect of both hemispheres. The pia mater in which they are seated is 
not injected. Base. — Moderate injection upon surface of anterior lobes ; the 
arachnoid around the commissure of the optic nerves is opaque and thickened. 
In the same spot there is a considerable effusion of yellow lymph-like matter^ 
extending along the anterior margin of the under surface of the middle lobe, 
from which it may be traced into the fissure of Sylvius. Grranulations very 
numerous, most abundant upon the upper surface of the cerebellum, which is 
not injected. Cortical substance pale ash colour; medullary pale ; the pos- 
terior lobe of the right hemisphere is much softened, being almost diffluent. 
The remaining lobes are healthy ; a few red points only, being observed on 
cutting into them. Corpus callosum, septum lucidum, and fornix very much 
softened, ventricles greatly distended, at least ^viij of serum having escaped, 
on the accidental separation of the hemispheres, through the softened corpus 
callosum. Thalami nerv. optic, of natural consistence ] left corpus striatum 
softened upon its surface; right healthy; lining membranes of ventricles 
slightly injected. 

Spinal marroiD of normal consistence; a moderate quantity of light, citron- 
coloured fluid at its lower part, the precise situation of which was not ascer- 
tained ; numerous small granulations were noticed throughout its whole ex- 
tent, seated apparently in the meshes of the pia mater, which is not in the 
least injected; they are also seen very abundantly upon the under surface of 
the medulla oblongata. 

Neck. — Larynx pale and moist; no ulcerations; glands of neck not ex- 
amined. 

Thorax. — Pleurse moist, not adherent; lungs rosy fawn colour anteriorly, 
posteriorly mottled with violet ; numerous granulations, of the size of pins' 
heads, are observed beneath the pleura, most abundant upon the upper surface 
of the lower lobe of the right lung, along its superior margin, where they are 
thickly agglomerated. The plem^a itself is not opaque, or thickened, nor in 
the least injected. Tissue of lungs crepitant, of a reddish-brown colour, 
somewhat engorged; they contain numerous granulations, which, however, 
are much less abundant than in many preceding observations ; they do not 
appear to be more numerous in the upper than in the lower lobes. Upon the 
posterior margin of the lower lobe, near its middle, is a tuberculous deposit 
two lines in diameter, of a light yellow colour, and of the consistence of ordi- 
nary tubercle. Lining membrane of trachea and bronchial tubes pale brick- 
dust red, apparently from imbibition; not injected, or thickened; bronchial 
glands enlarged and tuberculous; the largest is just within the bifurcation of 
the trachea; it is eight lines in length by five in breadth; nearly the whole of 
the gland is converted into a yellowish matter, of cheese-like consistence^^ 
softened in the centre. Several of the other glands of smaller size are completely 
infiltrated with tuberculous matter, and are also more or less softened. Heart. — 
Pericardium pale, containing a small quantity of citron-coloured serum. A 
solitary tubercle, of the size of a pin's head, is observed beneath the cardiac por- 
tion of it, upon the posterior surface of the heart. Length of heart eighteen 
lines, measured in a straight line from root of aorta. Breadth at base sixteen 
lines; circumference at base three inches and three-quarters Left ventricle 
empty ; parietes three lines in thickness, exclusive of columnse carnese ; a little 
fluid blood in right ventricle, walls a line in thickness; lining membrane 
healthy. 

Abdomen. — Peritoneum pale and moist; no effusion within its cavity. Liver 
of a reddish-brown colour, mottled with yellow, except upon its under surface 
along its anterior margin, where it is of a slate colour. Tubercles in great 



42 Hallo well on Tuhercular Diseases. [Jan. 

abundancej of the size of pins' headS; are found beneath its peritoneal coat, both 
upon its upper and under surface. Several of these are also observed within 
its substance ; one of them, on the under surface of the right lobe, near its 
anterior margin, is nearly two lines in diameter. Several of these deposits 
are undoubtedly tuberculous, having their usual appearance and consistence ] 
but others are of an orange colour, and, on squeezing them, there exudes a 
fluid having the appearance of bile ; one of them presents a dark point in its 
centre. Gall bladder moderately distended with dark-coloured bile, staining 
paper a greenish yellow. Stomach coated with a layer of brownish mucus, 
having a slightly offensive odour. Membrane pale, except along its lesser cur- 
vature, where there are several well-marked arborizations ; these are confined 
to the smaller ramifications of the larger vessels, which extend some distance 
upon the anterior and posterior faces of the stomach ; consistence normal, ex- 
cept at the great cul-de-sac, where it is thinner and softened, being readily 
scraped off in the form of a pulp by the finger nail. The softened portion 
is quite pale ; strips one inch in length are obtained along the lesser curva- 
ture, near its middle, and five or six lines at its pyloric extremity. The small 
intestine contains a quantity of orange-coloured mucus, which in the ileum 
assumes a greenish tinge. Mucous membrane of duodenum slightly injected 
at its upper extremity in a space of about three inches ; the mucous cryptaa 
here are quite distinct, but in the rest of the small intestine are scarcely 
visible ; with the exception of the portion just mentioned, it is perfectly pale 
throughout; perhaps a little softened, yielding strips from one to two lines. 
The plaques of Peyer are perfectly pale and healthy, except two, in the centre 
of which there is a small tuberculous deposit ; several of these are noticed in 
the sub-peritoneal tissue, but none beneath the lining membrane. Large intes- 
tine pale throughout, containing a considerable quantity of liquid yellowish 
feces; strips six to seven lines. Mucous cryptse highly developed, of an 
opaque whitish colour, and slightly elevated, the central point very indistinct ; 
no tubercles. Spleen two inches and three-eighths in length by one and a half 
in breadth, of a bluish colour externally, becoming red on exposure to the air. 
Tissue brownish red, friable, filled with tubercles ; they are also very abundant 
upon its surface, beneath the peritoneal coat. Right kidney two and a half inches 
in length by one and a quarter in breadth, of a reddish-brown colour exter- 
nally, mottled with yellow ; tubular and cortical portions pale ; four or five 
tuberculous deposits, of the size of pins' heads, of an opaque or dull white 
colour, are observed beneath its proper coat, imbedded in the cortical portion 
of the kidney. On cutting into it, one similar in size and appearance is ob- 
served in the tubular portion, just at its junction with the cortical. The 
left kidney presents the same general appearance as the right. Eight or ten 
tuberculous deposits are seen upon its surface, beneath its proper coat ; none 
observed in the tubular portion. Renal capsules healthy. 3Iesenteric glands 
pale, firm, not tuberculous. Bladder distended with urine of a light yellow 
or straw colour; lining membrane pale. Pancreas healthy. 



r 



1850.] Kneeland on Angina Pectoris, 43 



Art. II. — On Angina Pectoris. By Samuel Kneeland^ Jr., M.D., 

Boston, Massachusetts. 

The great variety of diseases to which " angina pectoris" has been referred, 
since its first description by Heberden in 1772, and the conflicting opinions 
of authors on its post-mortem appearances, even at the present day, show 
that its exact nature and seat are by no means definitely settled. 

Two years ago, the following case came to our knowledge ; and it struck us, 
at the time, that the usually received opinion concerning this affection was not 
confii'med by the most marked symptoms. Great as is the disagreement, 
among authors, as to the nature and seat of angina pectoris, there are certain 
characteristic symptoms which are generally understood as accompanying this 
affection. These symptoms were noticed in the case below. Lest any should 
have doubts as to its being a case of angina pectoris, we shall also take the 
symptoms of the disease as given by the best authorities, and see if the pre- 
sent condition of physiology will not warrant us in narrowing the list of dis- 
eases from which to choose, and perhaps in indicating its exact seat and 
nature. 

The subject of the following case was a gentleman of high standing and 
wealth; his age 52; short in stature, stout; of sanguine temperament; 
equable disposition ; what might be termed a '^ good liver.^^ For the last 
three years he had been subject, when walking, to attacks of dyspnoea, attended 
by a sense of constriction in the epigastrium, which compelled him to stand 
still for some minutes ; when this sensation ceased, he felt as well as ever. 
These attacks were not of frequent occurrence. Though he had mentioned his 
condition to physicians, he had never undergone medical treatment for it. An 
uncle of his had died suddenly, some years before, with similar symptoms. 

On New Year's eve, being in his usual good health, he remained late at a 
party with his children ; the following day he felt unwell. He complained of 
pain in the thorax ; had no appetite ; passed an uneasy night, but felt better the 
next morning, and rode about two miles to his place of business. He walked 
about one-eighth of a mile, and when near his store had an attack of pain which 
compelled him to stop ; its duration was so much longer than usual as to 
attract public attention. He was carried into a neighbouring store, when, after 
the administration of some peppermint, the paroxysm ceased. The symptoms 
during the paroxysm were loss of strength, dyspnoea, cold extremities, slight 
rigidity of limbs, frothing at the mouth, and cessation of the pulse. He was 
carried home in a carriage, but complained of no inconvenience from its motion. 
After arriving at his house, he had another paroxysm, similar in character, but 
more alarming than the first. 

All this occurred before 10 A. M. His physician first saw him at 1 J P. M. 
He was then in bed, looking like a person in an apoplexy ; stupid but half 
conscious; extremities very cold; pulse 100, very small and quick; respira- 



44 Kneeland on Angina Pectoris. [Jan. 

tion blowing. Different physicians liad given him gin^ etlier^ and stimulating 
enemata^ with but little relief; ammonia and sinapisms were advised, with 
some relief. On ausculting the heart, the sounds were almost obliterated by 
the tumult of respiration, which was very loud in both lungs ; this was soon 
changed by the occurrence of a mucous rale all over the lungs, attended by 
the expectoration of frothy sputa tinged with blood ; its copiousness alarmed 
him; he commenced an address to his children, which very much increased 
the dyspnoea ; he thought himself dying. 

At this moment, an eminent practitioner arrived (whose skill in ausculta- 
tion is well known), who had been sent for in consultation. In reply to his 
questions, the patient referred all his distress to his stomach, and said that the 
pain often spread from this organ through his arms, with a sensation of numb- 
ness. No information could be derived from a careful auscultation of the 
heart. He regarded it as an obscure case of angina pectoris, and advised a 
cathartic of calomel, the continued use of ammonia, and general hot fomen- 
tations. Other physicians, who had seen the patient before, made the same 
diagnosis. Soon after this the profuse expectoration seemed to abate, and the 
respiration became more free; at 4 J P. M., he declared himself quite com- 
fortable. 

At 7 P. M., the unfavourable symptoms returned in full force ; the copious 
muco-sanguineous expectoration threatened suffocation ; the pulse sank rapidly; 
a small dejection added to his exhaustion, and at 7f P. M. he died. 

Unfortunately, no autopsy was made ; however, as the views in this article 
will be based not merely on this case, but on the accumulated cases of the best 
authorities, this omission will be of less consequence. Moreover, as in other 
cases of angina, no lesion would probably have been found which would 
account for the symptoms ; lesions would doubtless have been discovered, but 
lesions often found in cases presenting entirely different symptoms. We shall 
speak at length of this, when treating of the pathology of angina pectoris. 

Before proceeding to state what we believe to be the nature and seat of 
angina pectoris, it will be necessary to give a brief sketch of the symptoms 
of the above case, as well as certain other phenomena of the disease, as de- 
tailed in the books. The symptoms in our case were pathognomonic; but cer- 
tain accessory phenomena usually observed, and necessary to the proper treat- 
ment of the subject, were absent; both of these, to avoid repetition, we shall 
combine in one description. 

The age, stature, physical condition, temperament, and habits of the patient 
were the same as in most recorded cases. The manner of seizure was what 
we should expect. The paroxysm comes on suddenly during walking, ex- 
ercising, facing a cold air, after indiscretion in eating or drinking, or from 
strong mental emotion The patient had stayed late at a New Year's party 
with his children ; the paroxysm ceased when the patient stopped his walk. 
Any excitation of the respiratory motions is sufficient to bring on an attack, 
during defecation, micturition, or even a change of position. The attacks 



( 



1850.] Kneeland on Angina Pectoris. 45 

come on suddenly in the midst of apparent health, often without premonitory 
symptoms; their appearance is irregular and intermittent, the patient enjoy- 
ing his usual health in the intervals. When slight, they are frequently 
attributed to rheumatism. As usual, the idea of a fatal termination haunted 
the patient. 

There is a constant and distressing dyspnoea, with great anxiety; the 
anxiety seems to be not from pain during respiration, but from difficulty in 
obtaining sufficient air for the proper oxygenation of the blood ; hence the 
respiratory movements are a little hurried in most cases, accompanied by 
panting, deep sighs,and yawning ; there is also a sense of constriction in the 
chest. There is frequently a sense of suffocation, referred to the larynx, with 
difficulty of speaking, or absolute inability to articulate; the last was not 
noticed in the above case. There was the usual copious frothy expectoration. 

The pathognomonic symptom of pain and constriction at the lower part of 
the sternum, rather to the left than the right side, was remarkable here. It 
seems to the patient as if an irresistible force was pressing his sternum against 
the vertebral column. This, according to Laennec and others, may exist 
wholly on the right side of the chest. From this point the pain radiates in 
all directions to either or both arms ; upwards to the neck, jaws, and sides of 
face ; downwards to abdominal viscera (particularly the bladder), and to the 
lower extremities. Of these sympathetic actions the most constant is the 
radiation to the arms ; this, from its singularity, arrests attention, and is useful 
in making a diagnosis. In the parts attacked by this pain, there is almost 
always, in severe cases, a sense of numbness, soreness, and stiffness in the 
course of the nerves. 

The pulse is only a little accelerated, and weaker than natural ; in cases where 
it is described as irregular, intermittent, and greatly accelerated, there is a com- 
plication of cardiac or aortic disease. Palpitations are rare, unless there is 
also an affection of the heart; when present, they must be considered as the 
feeble efforts of a distended organ to free itself from a blood insufficiently 
aerated. The cold extremities indicate insufficient circulation. 

The almost constant symptoms from the stomach are eructations of gas, 
and vomiting at the end of the paroxysm, which afford great relief; there are 
also swelling and soreness in this region. 

Other symptoms are loss of strength and consciousness, to a certain extent, 
in all cases ; in mild cases, the intelligence is unimpaired, as in the second 
paroxysm in this patient. 

Treatment has generally been pronounced useless : as usual, antispasmodics, 
stimulants, and counter-irritation were employed in this case; the stomachic 
symptoms were relieved by carminatives. Death was not sudden in this case. 
When it occurs during a paroxysm, it is usually sudden; but it oftener occurs 
during the intervals. 

A case came under our notice which presented symptoms, in addition to 
the characteristics of angina pectoris, which much resemble those of a case 
No. XXXVII.— January, 1850. 4 



46 Kneeland on Angina Pectoris. [Jan. 

alluded to by Dr. BlackalL* The patient was a sea-captain^ only thirty-five 
years of age. During the six months that we were with him, he had several 
paroxysms of angina pectoris, in which a most sudden and violent pain would 
fix him motionless for a few minutes ; in the principal symptoms, it agreed 
with most recorded cases. His temperament was exceedingly nervous. On one 
occasion, just after a violent storm at night, in which he had been very much 
excited, not to say alarmed, a severe paroxysm came on; he relieved it by his 
usual remedies, stimulants, a kind of hot drops in which the chief ingredients 
were cayenne pepper and brandy — but it left him with a painful twitching of 
the left deltoid muscle. This could be plainly seen under his coat. There was 
no swelling or redness, but pressure gave pain. The pain was not confined to one 
spot, but aifected different fibres of this muscle, and of no other ; it tormented 
him for several days, but finally yielded to blisters and opiated poultices : the 
muscular spasm was so strong as to overcome the utmost pressure of the 
hand. In other cases, there has been a similar affection of the diaphragm, 
the pectoralis major, and the thoracic muscles. 

Cadaveric examination has shown a great variety of lesions, upon which as 
many theories of this disease have been founded. The principal lesions have 
been found in the organs of circulation. These are ossification of the coronary 
arteries of the heart, with more or less obliteration of their cavity; dilatation, 
ossification, or ulceration of the aorta; cartilaginous or ossified mitral and 
semilunar valves; dilated, or hypertrophied, or atrophied heart; hardening or 
softening of its muscular substance ; fatty degeneration, or accumulation at 
its base ; adhesions and effusion in the pericardium. In the lungs have been 
found sanguineous effusions ; the bronchi are filled with a frothy bloody serum ; 
the substance of the lung very dense and heavy ; pleuritic adhesions, with or 
without effusion. Accumulation of fat, and abscesses, have been found in the 
mediastinum ; and ossification of the costal cartilages. 

With such symptoms and such morbid appearances before us, are we justi- 
fied in referring this affection to any determined organic lesion ? can we give 
it a " local habitation and a name ?" 

Though many of the single symptoms above mentioned are found in many 
thoracic diseases, it may be safely asserted that their combination is not met 
with except in angina pectoris. We prefer this name, as it can be confounded 
with no other, and prejudges nothing in regard to its nature. 

According to Raige-Delorme,")" Heberden and Hamilton referred it to an ill- 
defined spasmodic state; Rougnon and Baumes to ossification of the costal 
cartilages, causing obstructed respiration, and stagnation of the blood in the 
heart ; Fothergill and Black to accumulation of fat in the pericardium and 
about the heart ; ossification of the coronary arteries, and consequent dimi- 
nished nutrition of the heart, were the cause, according to Jenner, Parry, and 

* Observations on Dropsies. London, 1824, p. 406. 

f Diciionnaire de Medecine, vol. iii.,art. Angine de poitrine,p. 151. 



1850.] Kneeland on Angina Pectoris. 47 

Kreysig; ossification of the valves, &c. of the heart, according to Blackall. 
Others ascribed it to a spasm of the heart ; to a gouty, or rheumatic metas- 
tasis; to a spasm of the diaphragm and respiratory muscles ; to displacement or 
compression of the heart; and to various organic lesions of this organ. Jurine 
attributed it to an affection of the pneumogastric nerve, causing incomplete 
oxygenation of the blood, and asphyxia ; Desportes to a neuralgia of the pul- 
monary and cardiac plexus ; Bell to a lesion of the respiratory system of 
nerves ; Laennec to a neuralgia of the heart. 

As to organic lesions of the heart, it is perfectly idle, in the present condi- 
tion of auscultation and percussion, to bring them forward in this connection. 
The series of accompanying symptoms would lead to a diagnosis, in absence 
of the physical signs of cardiac disease. They may, perhaps, be occasional 
exciting causes ; from the age of the patients usually affected, they would very 
likely be found. They must be considered as complications, having nothing to 
do with the special symptoms. 

One theory, which was formerly much in vogue, and which even now has 
its supporters, explained the phenomena of angina pectoris by ossification of 
the coronary arteries of the heart. This originated with Jenner, and has since 
been maintained by Parry and Kreysig. Jurine supposes that, by this lesion, 
the dilatation of the heart might be obstructed whenever an abnormal quan- 
tity of blood was sent to, or retained in, the heart, which would compress the 
cardiac nerves, suspend the functions of this organ, and cause sudden death. 
This ossification is frequently found, but not always, in those who have died 
from angina pectoris ; when it has arrived at a very advanced stage, the nutri- 
tion of the heart may be so affected that, in its feebleness, it may not be able 
to expel its contents ; but, when it is found, the intensity of the symptoms 
bears no relation to the extent of the lesion, and often there have been co- 
existent valvular lesions. In many well-marked cases, these arteries have 
been found perfectly natural. Moreover, we think it very probable that a 
great many cases of this affection pass unnoticed in middle life, from the sup- 
position that it is peculiar to old age, when ossifications about the heart are 
as common as they are rare before the age of fifty. A deficient nutrition of 
the heart does not seem compatible with the strong constitution of the patients, 
their perfect health in the intervals of the paroxysms, and the condition of 
the heart's action and pulse ; it may be remarked that pain is the most com- 
mon symptom, and almost always precedes syncope ; and it is not always 
during a paroxysm that the patient dies. Abercrombie (see Diet, quoted) 
relates cases of ossification of these arteries without any symptom of angina 
pectoris. Females are as subject as males to ossification of these arteries ; yet 
they are rarely attacked with angina. There are well-authenticated cases of 
cure in this affection. Attacks, too, sometimes come on during sleep and rest, 
when there is nothing to excite the heart's action. 

"We think that both the symptoms and the morbid appearances prove that 
the seat of angina pectoris is not in the circulating, the respiratory, or the 



48 Kneeland <y)i Angina Pectoris. [Jan. 

digestive systems. We shall endeavour to show that it is an affection of the 
nerves supplying these systems ; in other words, that its seat is in the par 
vagum, or pneumogastric system of nerves, its branches, terminations, and 
communications. 

The nervous nature of this disease has been suspected ever since its first 
accurate description by Heberden, who ascribed it to an indeterminate spas- 
modic state. Jurine (1815) called it an affection of the pulmonary nerves, 
causing incomplete oxygenation of the blood, and asphyxia j Desportes called 
it a neuralgia of the pulmonary and cardiac plexuses ; Bell a lesion of the 
nervous system of the respiratory muscles ; and Laennec a neuralgia of the 
heart. 

We think it is a nervous affection, from the sudden manner in which the 
symptoms come and go, and their intermittent character ] from the pecu- 
liarity of the pain, and its sudden and extensive radiations, leaving the parts 
benumbed and painful, while at other times pressure relieves the pain ; from 
the inconstancy, and even the entire absence, of morbid lesions ] from the 
undoubted cure in many cases ; and from the nature of the medicines most 
successful in its treatment — opiates and antispasmodics. The relation of 
angina pectoris to essential or idiopathic asthma we believe to be very inti- 
mate. We shall compare them below. 

Let us now examine the anatomy and physiology of the respiratory nerves j 
and the sympathetic system, to see whether both, or the former alone, are inte- 
rested in this disease. We shall take for authorities Longet (^Systeme Nerveux^ 
Paris, 1842), and Carpenter {Principles of Human Physiology j Philadelphia, 
1847), with such references in these authors as we have been able to consult. 

The spinal marrow, as distinguished from the medulla oblongata, has very 
little, if anything, to do with the respiratory movements ) it can only be con- 
sidered as a simple conductor for these movements. The medulla oblongata 
must be considered as the origin and regulator of all such movements. It is 
now generally admitted that those nerves connected with the external respira- 
tory acts, upon which Sir Charles Bell laid so much stress, are intimately 
connected with this great centre. The spinal accessory of Willis, the facial, 
the phrenic, the external respiratory of Bell, and the intercostal nerves, aris- 
ing apparently from the spinal marrow at different heights, all, according to 
Carpenter (p. 294), are connected with the gray matter of the medulla 
oblongata. He says, as this, " in vertebrated animals, is the chief centre of the 
actions of respiration, it can scarcely be doubted that all the nerves concerned 
in that function have a direct structural connection with it." 

The medulla oblongata, like the spinal marrow, is very sensitive posteriorly, 
but insensible in front. It transmits impressions and the principle of volun- 
tary movements ; it has also a strong reflex, or excito-motor action ; but it 
is also the central point of the respiratory nervous system. According to 
Flourens, this central point extends from immediately above the origin of the 
par vagum to about three lines below this origin. On this point, '•^ respiration, 
the exercise and unity of the nervous action, in a word, the whole life of 



1850.] Kneeland on Angina Pectoris. 49 

the animal, depend." According to Longet (torn. i. p. 395), you may remove the 
whole contents of the cranial cavity, leaving the medulla and the spinal mar- 
row untouched, and yet the respiratory movements will continue with great 
regularity ; but the moment you remove a segment containing the origin of the 
par vagum, with some radical filaments of the spinal accessory, the respiratory 
movements cease, especially the contractions of the diaphragm, serratus magnus, 
and intercostal muscles, and the animal dies in a state of asphyxia ; and still the 
phrenic, the external respiratory, and the intercostals have their apparent 
origins in the spinal marrow untouched. Not only the- respiratory movements, 
hut all the other parts of the nervous system must be connected with this 
point, in order to exercise their functions ; so that Flourens has justly called 
it the ^^ noeud vital du systeme nerveux.'^ 

From the intimate connection of the par vagum with the sympathetic 
system, its distribution to so many diiFerent organs, and the difficulty of expe- 
rimentation on its separate branches, its experimental history has become 
somewhat complicated. For its physiological relations to be fairly before us, 
we must give a brief sketch of its anatomical distribution and connections. 

In its structure, the par vagum differs from the other cranial nerves by the 
delicacy of its filaments and their plexiform arrangement ; by these, and by 
its distribution, it more resembles the nerves of organic than those of animal 
life ; and it probably will be found that this nerve forms the connecting link 
between the two. 

Oken and Carus have decomposed the cranium into three cranial vertebrae ; 
and the cephalic nerves have been divided into three spinal nerves of the cra- 
nium. The history of embryological development shows this to be a philoso- 
phical arrangement. Considering, then, the trigeminus as the first spinal 
nerve of the head, the second is the facial and the glosso-pharyngeal, and the 
third the par vagum and the spinal accessory ; the hypoglossal being the first 
true spinal nerve. This will introduce, below, the relation of the sympathetic 
to the spinal nerves. 

Since the researches of Arnold, Scarpa, Bischoff, and Longet, we can no 
longer doubt that the par vagum and the spinal accessory form a pair of nerves, 
the former representing the posterior or sensitive root, and the latter the motor 
or anterior root. This is shown also by their distribution, the former supply- 
ing the glands and mucous membranes, the latter contractile parts only. 

The pneumogastric nerve arises from the restiform body on the posterior 
surface of the medulla, by a great number of very delicate filaments, just be- 
low the origin of the glosso-pharyngeal. The spinal accessory takes its origin 
only from the lateral surface of the medulla, as low as the fifth cervical nerve. 
Both come out of the cranium in the same sheath of dura mater: the spinal 
anastomosing with some of the cervical nerves; the pneumogastric, at its 
ganglion and plexus, anastomosing with the facial and glosso-pharyngeal 
nerves, the carotid filament of the superior cervical ganglion, and the spinal. 
The external branch of the spinal is distributed to the trapezius and sterno- 
mastoid muscles. Its internal branch unites with the pneumogastric, forming 



50 Kneeland on Angina Pectoris. [Jan. 

a mixed trunk anastomosing with the superior cervical ganglion^ the hypo- 
glossal nerve^ and sometimes the cervical plexus. There is, sometimes, accord- 
ing to Longet, a kind of fusion of the par vagum with the superior cervical 
ganglion. The two nerves now become one; and, when we speak of the par 
vagum, we include the spinal accessory. In the neck, it gives off the pharyn- 
geal branch to the superior and middle constrictors of the pharynx; the 
superior laryngeal to the inferior constrictor of the pharynx, laryngeal mucous 
membrane, glands, vocal chords ; and the cardiac branches, either anastomos- 
ing with the superficial cardiac nerve, or going directly to the anterior cardiac 
plexus, and the left side passing in front of the arch of the aorta. With the 
sympathetic nerve they here form the pharyngeal and laryngeal plexus. In 
the thorax, the left nerve passes in front of the aortic arch, divides into a 
great number of branches, near the root of the lung, which again unite to 
form the left oesophageal nerve to this organ and the stomach. A similar 
branch to the oesophagus is formed on the right side. It anastomoses with 
its fellow of the opposite side, which is almost peculiar to this nerve and the 
sympathetic ; with the branches of this last it forms the oesophageal, cardiac, 
and pulmonary plexuses. In the thorax, it gives off the inferior laryngeal or 
recurrent nerve, which furnishes branches to the neighbouring plexuses, espe- 
cially the cardiac, and is itself distributed to all the laryngeal muscles, except 
the crico-thyroid (which is supplied by the superior laryngeal), to the mucous 
membrane and the muscular fibres of the trachea and oesophagus. Besides the 
cardiac branches, it sends its filaments along the bronchial ramifications, sup- 
plying their muscular and mucous tissue. With the thoracic ganglia they form 
the pulmonary plexuses, which communicate very freely with each other, thus 
explaining the comparative harmlessness of division of the par vagum on one 
side only. The oesophageal branches supply both the mucous membrane and 
muscular fibres of the stomach; the last communicate with the hepatic and 
solar plexus. The remarkable anastomoses between the par vagum and the 
sympathetic show the tendency to fusion between these two nerves, both 
in man and the lower animals. Weber (1817) maintains that the latter is 
not the sole visceral nerve, the par vagum having a similar function. In fact, 
as we descend the animal scale, we find the par vagum increasing, while the 
sympathetic diminishes, in importance. In fishes, the latter is hardly percep- 
tible, while the par vagum of both sides is nearly as large as the spinal mar- 
row itself, and presides almost entirely over the visceral functions. (Longet, 
tom. ii p. 261.) 

We have seen that the pneumogastric and the spinal accessory are distri- 
buted to the lungs, heart, and stomach ; to the larynx and trachea, pharynx: 
and oesophagus. Their functions must therefore be of the highest importance, 
and their diseases especially worthy of study. 

Shall we adopt the opinion of Longet as above quoted ? or that of Reid 
and others, that the par vagum has motor roots of its own, and the spinal 
accessory sensory roots ? or say, with Carpenter, that the roots of the spinal 



1850.] Kneeland on Angina Pectoris. 51 

accessory are cliiefly motor^ and those of the par vagum cliiefly sensitive, each 
supplying the other with its peculiar fibres ? Longet's experiments seem to 
show satisfactorily that the origins of these nerves represent the two roots of a 
spinal nerve; that in its trunh it is a nerve of double endowment, very differ- 
ently distributed among its branches. 

There is no motor nerve upon which movements so necessary to the main- 
tainance of life depend, as the spinal accessory; and this we should, ci priori j 
expect from its peculiar origin. On it depend the mechanical phenomena of 
respiration and digestion, and some perhaps of the circulation. ^^ Show me,^^ 
says Longet, ^^ another nerve in the economy, whose physiological mission is 
so high (the sympathetic excepted), and I shall perhaps cease to wonder at an 
origin so exceptional.'' These movements are not liable to be suspended 
from ordinary causes, from the great extent of its spinal insertions. 

From the experiments of Longet and Reid, we know that respiration is not 
affected by section of the superior laryngeal nerves. By section of the ex- 
ternal branch, the voice becomes hoarse from paralysis of the crico-thyroid 
muscles. The exquisite sensibility of the larynx depends on the internal 
branch. 

The section of the recurrent nerves in animals, and their lesion in man, is 
followed by an alteration or loss of the voice, and more or less trouble in re- 
spiration. The voice is destroyed on their section, except in young animals. 
It has long been known that sudden death may occur in animals on section of 
the recurrents, or the pneumogastrics above their origin. This is not due to 
occlusion of the glottis from paralysis of the laryngeal muscles and non-para- 
lysis of the constrictors, for the recurrents are distributed to all the muscles 
of the larynx except the crico-thyroid, and thus influence both the constriction 
and dilatation of the glottis. Though all the muscles are paralyzed, there is 
no symptom of suffocation while the animal is quiet ; but, on any unusual re- 
spiratory movement, the arytenoid cartilages (whose muscles are paralyzed) are 
pressed down by the current of air upon the opening of the glottis, causing 
perhaps fatal suffocation. This may be obviated by an opening in the trachea. 
According to Longet, respiration is accelerated after section of the recurrents ; 
the aperture of the glottis being smaller, the number of inspirations in a 
given time must be greater for the proper aeration of the blood. 

The bronchial ramifications are lined with a mucous membrane, strengthened 
by muscular fibres ; the sensibility of the one, and the contractility of the 
other, are dependent on the mixed trunk of the pneumogastric. Pulmonary 
respiration comprehends the sensation of the ^^ besoin de respirer,'' certain 
mechanical phenomena, and the chemical or vital phenomena of hematosis. 

Many authors maintain that the sensation of the ^^ besoin de respirer" is 
annihilated by section of the pneumogastrics ; but still the respiratory move- 
ments continue. The researches of Longet and Eeid go to prove that this 
sensation is not destroyed by the section of these nerves, and that the respi- 
ratory movements become slower ; impressions made on the pulmonary mucous 



52 Kneeland on AngiJia Pectoris. [Jan. 

membrane are conveyed to the medulla oblongata by the pnenmogastrics ; 
this must also be the seat of the " besoin de respirer/^ and not the pulmonary 
surface ; if this nerve be divided^ the impression is no longer conveyed, the 
" besoin" will be less, and require fewer respiratory movements. This sen- 
sation is due either to the presence of venous blood in the capillaries of the 
lungS; or, as Marshall Hall supposes (and more justly, we think), to the pre- 
sence of carbonic acid in the air-cells. There is no proof, experimentally, that 
the numerous anastomoses of the sympathetic are primarily concerned in con- 
veying such impressions ; though, when the blood has become vitiated, their 
distribution on the vessels may enable them to convey additional impressions. 
In order to annihilate the " besoin de respirer," we must then destroy not 
only the pneumogastrics, but the medulla oblongata itself. 

The pneumogastrics are the principal excitors of the respiratory movements, 
and their section very much diminishes the number of respirations. Whether 
impressions are received by the nerves distributed to the general surface, and 
by the sympathetic, and to what extent the encephalon influences these move- 
ments, are questions foreign to our present purpose. The motor nerves con- 
cerned in respiration are the spinal accessory, the phrenic, the intercostals, and 
the facial. The internal respiratory movements are also under the control of 
the pneumogastrics. These depend not on any active expansibility of the pul- 
monary tissue, but on the contractility of the muscular fibres of the bronchial 
ramifications. This muscular contraction is the more necessary, as the air in the 
deeper pulmonary vesicles is charged with carbonic acid, and therefore heavier, 
and less easily expelled. The result of the paralysis of these muscles is, there- 
fore, insufficient oxygenation of the blood, and asphyxia, which is aggravated 
by the accumulation of the mucosities whose expulsion depends on the action 
of these muscles. 

The influence of the par vagum on hematosis is only indirect. The disturb- 
ance of this essential act, and its final cessation, on section of these nerves, 
depend on alterations in the lungs, and not on the direct suppression of 
nervous influence. Of course, we do not refer to any obstruction to the en- 
trance of air at the opening of the glottis. The diminution of the respiratory 
movements causes an insufficient introduction of oxygen, and the blood is im- 
perfectly arterialized ; there is stagnation of blood in the capillaries of the lungs, 
with congestion, and effusion of serum into the air cells and bronchial tubes ; 
in many cases, the lungs are so congested and condensed as to sink in water, 
and cease to crepitate. Besides this serous effusion, the natural secretion of 
the bronchial mucous membrane (depending on the sympathetic nerve) is ac- 
cumulated in the air passages, and adds to the trouble of incomplete hema- 
tosis. This mucus is no longer perceived ; and, if it be, the muscular tunic of 
the bronchi can no longer act to expel it by cough ; by the diminished respi- 
ration, less mucosity is expired in the form of vapour ; and probably absorption, 
which would remove a portion of it, is lessened in lungs whose circulation is 
so obstructed, and whose texture even is so changed. It will be at once 



1850.] Kneeland on Angina Pectoris. 53 

perceived that these are precisely the lesions of the lungs found in angina 
pectoris. 

The par vagum is not without its influence on the heart ; as its division, and 
mechanical or galvanic irritation, modify its movements. Weber has shown 
that its movements may be immediately arrested by the transmission of an 
electric current from a rotating magnet either through the spinal cord or the 
vagi, divided at their origin (Carpenter, p. 547) ; but, from the nature of 
this stimulus, the sympathetic filaments might have been acted upon as well 
as the par vagum. Haller and others have maintained that the tissue of the 
heart is without nervous filaments ; but, in large animals especially, their pre- 
sence is very evident; only, according to Longet (p. 312), you can rarely 
follow as far as the heart the pneumogastric filaments isolated and distinct 
from the sympathetic ; so that you cannot be sure of irritating one without 
the other. By these nervous filaments, we can, however, in no way explain 
the sudden deaths in angina pectoris, as the heart will contract independently 
of nervous influence. The true stimulus of the heart is the blood ; the im- 
perfect arterialization of this fluid, after section of the pneumogastrics, will of 
course influence its contractions, secondarily. It is probably by the par vagum 
that the encephalon modifies the heart's action in mental emotions. 

The sensations and muscular contractions of the oesophagus depend on the 
influence of the par vagum ; on their section its retentive powers are destroyed^, 
so that the action of the diaphragm and abdominal muscles causes regurgita- 
tion of aliments which have reached the stomach. The par vagum, by its 
spinal branch, presides over the movements of the stomach during chymifica- 
tion. It no more presides over the sensation of hunger and thirst than it does 
over the " besoin de respirer ;" that is, the imperious demand for food, after 
long abstinence, continues on the section of this nerve, while the local sense 
of emptiness, which is relieved by the ingestion even of non-nutritious sub- 
stances, seems to be unperceived. The section of these nerves does not prevent 
the secretion or the acidity of the gastric juice, though its quantity is di- 
minished by the paralysis of the stomachal movements ; hence digestion must 
be very slowly performed, and in a manner improper for the preservation of 
life. 

Longet' s experiments show that the section of both pneumogastrics and 
sympathetics, in the neck, produces precisely the same consequences as regards 
respiration, circulation, and digestion, as when the former only are divided ; 
their numerous anastomoses at the lower portion would explain this. ( Op. cit., 
tom. ii. p. 346.) 

It is probable that many of the phenomena of angina pectoris are modified 
by the intimate connection of the great sympathetic nerve with the par vagum. 
The sympathetic can no longer be considered as a continuous system, com- 
posed of fibres peculiar to itself, but as a series of anastomotic arches, 
depending on filaments of the cerebro-spinal system mixed with ganglionic or 
gray matter; having, therefore, sensory and motor filaments, distributed to 



54 Kneeland on Angina Pectcn^is. [Jan. 

the vessels, glands, and parts over wliicli the will has no influence. The 
innumerable anastomoses, and often apparent fusion, of the par vagum and 
the sympathetic have already been alluded to. In the cardiac, pulmonary, 
and solar plexuses, there is not only an intimate connection of the cerebro- 
spinal with the sympathetic nerves, but of the left branches of the latter with 
the right, by which relations are established between distant organs. Accord- 
ing to Carpenter, it may fairly be inferred that the sympathetic does not supply 
anything essential to the performance of the organic functions, as it is .not 
developed in proportion to their activity, but that it only controls and brings 
them into relation with the animal functions. Indeed, in some fishes and 
reptiles, the par vagum supplies the intestinal canal and the heart ; even in 
the higher vertebrata, some of the glands are supplied with most of their 
nerves from the cerebro-spinal system. 

According to Cruveilhier, no part of the nervous system offers so many 
varieties as the cardiac nerves; except at their terminal distribution, which is 
uniform. The fusion of the par vagum with the sympathetic is very mani- 
fest here, as well as in the thoracic portion, which furnishes the splanchnic 
nerves, ending in the solar plexus and its numerous radiations. The sympa- 
thetic cannot act independently of the cerebro-spinal system; the two systems 
act reciprocally on each other. Impressions on the former are not generally 
perceived, and the will has no control over the movements it excites, because 
these impressions are lost in the spinal marrow, and its fibres do not reach the 
source of voluntary motion. That contractions of involuntary muscles con- 
tinue for a time independently of the brain and spinal marrow, Longet ex- 
plains by saying that the nervous principle in the sympathetic ramifications 
exhausts itself by successive periodic discharges. The spinal accessory 
establishes the transition between the cerebro-spinal and sympathetic nerves ; 
as it animates muscles both of animal and organic life, and has a mode of 
origin, similar to the latter, from a considerable portion of the cord. Many 
of the phenomena once explained by the sympathetic are now known to depend 
on the reflex action of the true spinal cord. 

The secretion of the pulmonary mucous membrane depends on the sympa- 
thetic, as it surely continues after the section of the par vagum. Haller and 
his school maintain that the nervous system has no influence on the contrac- 
tions of the heart ; but it is certain that they may be modified by stimulants 
applied both to the par vagum and the sympathetic, and especially to the 
spinal accessory (^Longet, p. 599). Irritation of the spinal marrow itself, in its 
cervical portion, affects its contractions. According to Longet (p. 606), the 
sympathetic is concerned in the heart's action only as the conductor of an in- 
fluence derived from the cerebro-spinal axis. If, in foetuses without brain 
and spinal marrow, there has been a high degree of development, in which 
the sympathetic ganglions (always in such cases, according to Breschet) have 
become so enlarged as to be capable of supplying to a certain extent the 
nervous power, it must be remembered that a foetus has no proper individual 



1850.] Kneeland on Angina Pectoris. 55 

life, Ibut is a part of the mother's organism, and that it by no means follows 
that, in the adult, the sympathetic alone can suffice for the heart. 

The secretions of the pharynx and oesophagus, and the gastric juice depend 
on the sympathetic system. 

The fibres, discovered by Miiller and Remak, and supposed peculiar to the 
sympathetic, are also found, though in less number, in the common cerebro- 
spinal nerves. From innumerable facts and experiments, we must acknow- 
ledge the great analogy of the former to the latter. Even the functions of 
nutrition and secretion are often dependent solely on the latter (e. g. the 
mammary gland receives nervous filaments only from the third and fourth 
thoracic pairs ; Longet, tom. ii. p. 634) -, the difference depending probably 
on different origins, the sympathetic being continuous especialli/ with the gray 
substance of the spinal cord, the cerebro-spinal nerves with its wliite sub- 
stance. 

We thus find that both anatomy and physiology favour the opinion we 
advanced, viz., that the disease called '^angina pectoris'' has its seat in some 
portion of thenar vagum system of nerves. Let us now examine the causes 
and symptoms from this point of view, in further confirmation of this. 

The exciting causes are those which act on the lungs, heart, and stomach, 
over whose sensations and motions the par vagum presides. The causes which 
act on the lungs are the action of a cold wind, when the patient faces it, the 
pain ceasing when the back is turned to it ; muscular exertion (acting also 
on the circulation), walking, running, going up stairs, cough, sneezing, talk- 
ing; even the passage of the feces and urine; in fact, all motions accele- 
rating the respiration or circulation. To these may be added excess in eating 
or drinking, and strong mental emotions, especially anger. 

In Longet's experiments on dogs (op. cit., tom. ii. pp. 349-50), the section 
of one pneumogastric caused a hoarseness of the voice, and a laryngeal whis- 
tling after exercise. In angina, we find the same affection of the voice, even 
its total extinction, and a similar respiration, denoting a diminution in the 
opening of the glottis ; also a sensation of strangulation from the same reason. 
Over these functions the superior and inferior laryngeal branches of the par 
vagum preside. 

The ^'besoin de respirer," and the sensation of imperfectly arterialized 
blood, cause a subsequent acceleration of the respiratory movements, present- 
ing the peculiar appearance of a dyspnoea without painful inspiration, as be- 
fore mentioned; the greater the affection of the par vagum, the less will the 
^^besoin" be felt, and the slower and more laboured will be the breathing. 
Sighing and yawning are almost always present; these are only long-drawn 
inspirations, the involuntary results of deficient aeration of the blood. There 
is usually absence of cough, as irritations are not properly conveyed to the 
medulla oblongata, and the motor influence of the spinal accessory is more or 
less diminished. The peculiarities of the respiration, as distinguishing angina 
from asthma, we shall give below. The copious frothy expectoration is fully 



56 Kneeland on Angina Pectoris. [Jan. 

accounted for by the insufficient hematosis^ and the consequent pulmonary 
congestion and effusion into the bronchial ramifications. These are fully ex- 
plained by the suppressed influence of the par vagum. 

The heart's action is but little affected, primarily, from its gTeater independ- 
ence of the nervous system ; yet the pulse is secondarily affected, indicating 
an increased exertion of an organ oppressed by an accumulated unarte- 
rialized blood ; its action finally ceases, with a sensation of syncope, which is 
sometimes more striking than pain in this disease. The coldness of the sur- 
face and extremities is the natural result of the obstructed respiration and 
circulation. 

The end of the paroxysm is generally announced by vomiting and eructa- 
tions ; the former is explained by the par vagum, as above mentioned ; the 
latter is observed in almost all nervous diseases, and here would be explained 
hj the numerous connections between the par vagum and the sympathetic. 
When the disease is severe and of long continuance, the digestive functions 
are imperfectly performed, and emaciation follows — the consequence of the 
non-conveyance of certain stomachal sensations upon which a regular appetite 
depends, and the cessation of the digestive motions of this organ. 

There are also pain and constriction referred to the lower part of sternum 
and epigastric region, radiating to the arms, neck and head, and abdomen. 
These are by no means peculiar to angina pectoris ; they must be explained 
here by the nervous communications between the par vagum, sympathetic 
(solar plexus), phrenic, and cerebro-spinal nerves. Spasmodic contractions 
of muscles, of the pectorals, deltoid, serratus, diaphragm, of the face and jaws, 
are in like manner explicable by the anastomoses of the spinal accessory with 
other motor nerves of respiration, all of which communicate with the respira- 
tory tract of the medulla oblongata. 

The cerebral functions are unaffected. 

These are the symptoms of simple angina pectoris, which are easily expli- 
cable on this theory of its nature and seat. There are complications of various 
other pulmonary, cardiac, and gastric diseases, with their special symptoms, 
with which we have nothing to do here, as they could not impose themselves 
on a careful observer as the original affection. 

There are many cases, in the books, of diseases resembling angina pectoris 
in their symptoms, in which various lesions of the par vagum and its branches 
have been found. By Longet (pp. 364-7), the following are mentioned : 
aneurism of the arch of the aorta, with atrophy, from pressure, of the left 
recurrent, causing paroxysms of suffocation ; both recurrents compressed by 
encephaloid tumours, with asthmatic symptoms, suffocation and constriction in 
the larynx; rupture of laryngeal nerves, with suffocation, cold extremities, 
aphony, but no loss of intelligence ; many cases, in children, of fatal suffoca- 
tion, where the pneumogastrics and recurrents were compressed by hypertro- 
phied or tuberculous cervical and bronchial glands; asphyxia caused by 
compression of recurrents by an encephaloid tumour ; whistling, and prolonged 



1850.] Kneeland on Angina Pectoris. 57 

inspiration; a case of chronic dyspnoea in AndraFs Cliniqne (torn. iii. obs. 
21), in which both pneumogastrics were compressed and obliterated by en- 
larged glands; analogous cases in the Gazette Medicale, 1834 and 1837, and 
Bullet, de la Societe anat. 1837; a case by Blandin (in Dictionnaire, vol. 
XV. art. Nerf) ^^of a kind of angina pectoris/' in which a tumour, of the 
size of a large pea, of a hard grayish tissue, apparently the result of an internal 
vegetation of the neui'ilemma, was found in one of the pneumogastrics, Mr. 
Swan relates a case in which the pneumogastrics were atrophied in the neck, 
in which there was difficult respiration, with whistling in the larynx ; what- 
ever amount of food was taken, hunger was not appeased ; the food was vomited 
undigested, after remaining some hours in the stomach ; emaciation : he had 
met with two other similar cases. Carpenter (p. 548) alludes to a case (in 
the Brit, and For. Rev., Oct. 1841) in which there was irregular action of the 
heart, with great anxiety, and acute pain passing up to the head from both 
sides of the chest ; these symptoms were caused by pressure of an enlarged 
bronchial gland on ^^ the great cardiac nerve ;" the connection of this with the 
pneumogastric would explain the phenomena. He says, " It may be surmised 
that, in many cases of angina pectoi'is, in which no lesion sufficient to account 
for death could be discovered, some affection of the cardiac plexus might have 
been traced, on a more careful examination." To this we would subscribe, only 
observing that, from the inseparable connection of this plexus with the par 
vagum, and the impossibility of compressing its sympathetic without its pneu- 
mogastric filaments, the sensa.tions conveyed and the consequent symptoms 
must depend principally and primarily on the par vagum. 

The causes of death in angina pectoris act on the lungs, heart, and stomach, 
separately or combined. Death by the lungs results from asphyxia produced 
by the congestion and effusion above noticed. The copious expectoration in our 
case leads us to suppose that asphyxia wa« the cause of death. From recorded 
cases, we should judge this to be the most common cause of death in this 
disease. Similar results have been noted in animals, when the divided ends 
of the nerves have been so far apart that no nervous transmission could take 
place. Inattention to this has led many experimenters to wrong conclusions. 
When life has been prolonged, the lung or lungs have been found atrophied to 
a considerable extent. 

The death is often sudden in this disease. This may happen from occlusion 
of the glottis ; from syncope, when there is co-existent cardiac or aortic lesion. 
Mayer (Longet, tom. ii. pp. 305-6), from his autopsies, was led to attribute 
the fluidity of the blood to the influence of the pneumogastrics, and to the 
abolition of this influence the coagulations he found in the heart and large 
vessels. Longet, to satisfy himself that these were not simple cadaveric lesions, 
instituted a series of experiments on this point. He killed animals at various 
times after he had cut the par vagum, and found as follows: After 20 hours, 
when there was no pulmonary congestion, the blood was very fluid ; after 
36 hours, small, soft, black clots (like currant jelly) in the auricles, ventricles, 



58 Kneeland on Angina Pectoris. [Jan. 

and origin of tlie aorta and pulmonary artery^ with congestion in some parts 
of the lungs ; on the 3d and 4th day, the congestion was very great, with 
firm yellowish clots between the columnae carneas, and even in the ramifica- 
tions of the pulmonary arteries and veins. These may he considered, then, as 
one of the causes of sudden death in angina pectoris. 

The last cause of death is from the consequences of impaired digestion; 
though death will be likely to occur from the other causes before this would 
have time to operate. It is most likely that the aff'ection of all these organs 
at the same time brings on the fatal termination. The various complications 
of the heart and large vessels, found in advanced age, may frequently cause 
death in those suffering under angina pectoris, and thus mislead us as to the 
true nature of this disease by supposed characteristic morbid appearances. 
After what has been said, we should expect to find the morbid lesion in the 
par vagum system of nerves. 

Having given what we believe to be the true seat of angina pectoris, its 
symptoms and their explanation, we may now consider its nature. If the par 
vagum be affected, what is the nature of this affection ? As in other portions 
of the nervous system, its affections are manifold. 

The par vagum, like other sensitive nerves, may become the seat of disor- 
dered sensation ; it may be affected with neuralgia ; angina pectoris, depending 
on neuralgia of this nerve, is characterized by the same excruciating pain, 
sudden in its appearance and disappearance, arising from similar causes, and 
benefitted by the same treatment as neuralgia in other nerves. It may arise 
from irritation of this nerve at its origin in the medulla, in its trunk, or in 
its visceral extremities. When the medulla is affected, there will generally be 
tenderness over the corresponding portion of the spine ; the spinal irritation 
or sensitiveness permits mild stimulants, which in a state of health are natural 
or harmless, to cause the most acute pain ; as the sensation of cold air in the 
lungs in the paroxysms of this disease. There may be great suffering, without 
serious injury to the health; but, if the nervous centre be affected, or the irri- 
tation be communicated to the numerous connections of this nerve, serious 
functional trouble is the result. In some cases, the neuralgia may depend on 
exciting causes in the organs of circulation (as irritation of the recurrents from 
disease in the arch of the aorta, and possibly of other branches from ossifica- 
tion even in the coronary arteries) ; but we believe, in most cases, the medulla 
oblongata is the seat of irritation, whenever angina pectoris depends on neu- 
ralgia ; and to this we refer a great many cases. 

Next to neuralgia is rheumatism, as a cause of this affection. Authors are 
ao-reed that, in many cases of angina pectoris, the patients have had a rheu- 
matic diathesis; the disease is often mentioned as disappearing during attacks 
of rheumatism, and reappearing on the subsidence of the rheumatic symptoms ; 
in other words, angina pectoris is in these cases a metastasis of rheumatism. 
Without discussing the question of the relations of neuralgia and rheumatism, 
or whether the latter affects only a certain tissue, we have in the nerves the 



1850.] Kneeland on Angina Pectoris. 59 

very fibrous structure on wtiicli so much stress is laid ; the neurilemma is of 
fibrous, structure^ and by common consent may very properly be affected with 
rheumatism. Rheumatic angina pectoris accords very well with the predis- 
posing and exciting causes of many caseS; as well as with the symptoms and 
treatment. 

Neuritis may occasionally cause the disease ; as also contusions, and acci- 
dental wounds. The records of surgical operations on the neck would doubtless 
yield many a case of excision, ligature, cauterization, or other wound of one or 
both pneumogastricS; accompanied with symptoms of angina pectoris. Can- 
cerous degenerations, and various tumours implicating these nerves, have not 
unfrequently been known to cause paroxysms resembling angina pectoris. In 
addition to the cases above mentioned, we may allude to one in the Dublin 
Journal (Nov. 1834), in which the symptoms of angina were explained by 
the envelopment of the par vagum in a mass of tuberculous glands. In this 
case, the respiration seemed to be carried on by the voluntary action of the 
muscles. A case is mentioned also by Dr. Blackall, in which the patient felt 
that the act of breathing required a voluntary effort. This was also noticed in 
the case of the celebrated Hunter, who died of this disease. These show the 
brain to be unaffected, and perhaps the partial dependence of the respiratory 
movements on this organ. 

The par vagum contains motor filaments from the spinal accessory nerve ] 
these may be affected independently of the sensitive filaments, and, when this 
takes place, we have idiopathic, or essential asthma ; but, as the motor filaments 
are rarely affected without the sensitive filaments of this nerve, and vice versd, 
there is almost always a mixture of asthma with angina. There is, we believe^ 
an intimate connection between these diseases, both being affections of the 
par vagum, the one of its motor fibres, the other of its sensitive fibres ; and; 
according as one or the other system is most affected, we have angina or 
asthma. Once for all, let us say we mean here idiopathic asthma; the 
symptomatic, being but a symptom, should be considered and described as 
such, and not as a special disease. Let us see whether the symptoms will 
bear us out in this opinion. 

The intimate relations between asthma and angina seem to have been per- 
ceived by most writers on the latter, as the diagnostic marks of both have been 
given together. Darwin has given angina the name of painful astbma. 

Both come on by sudden paroxysms, at irregular intervals. In both, there 
is a sense of painful constriction and suffocation, of epigastric tension with 
eructations ; yawnings ; coldness and paleness of the face ; the pulse compara- 
tively unaffected ; difiiculty of speaking ; the health good in the intervals, until 
the arrival of secondary causes of dyspnoea (usually emphysema, or other 
symptomatic asthma). Both are alike brought on, and influenced, by atmo- 
spheric changes; by the action of a cold dry wind; by mental emotions; per- 
haps also by hereditary predisposition. Both have been ascribed to the same 
lesions of the respiratory and circulating systems, even to ossification of the 



60 Kneeland on Angina Pectoris. [Jan. 

costal cartilages, coronary arteries, and cardiac valves ; both are relieved by 
tbe same treatment, narcotics, antispasmodics, and revulsives. Many cases 
of angina are recorded (see cases second and fourth of Dr. Blackall) in which 
symptoms of asthma at first appeared, and disappeared in the course of the 
disease : viz., fits of nightly sufi"ocation, after the first sleep, which compelled 
the patient to fly to an open window for relief. 

The differences between angina and asthma may be explained by the dif- 
ferent functions of the filaments of sensation and motion in the par vagum. 
In asthma, the dyspnoea is more characteristic than pain ] every muscular 
power is brought into action to introduce air into the lungs ; the diaphragm 
and pectorals contract convulsively ; the anxiety for air is extreme, and the 
patient seems continually on the point of suffocation. During the paroxysm, 
there is more or less absence of the respiratory sounds, from the difficulty the 
air finds in entering the pulmonary vesicles; hence the violent and noisy 
laryngeal respirations. When the fit ceases, there is copious expectoration, with 
mucous rales, and cough. The muscular fibres of the bronchi and their rami- 
fications are animated by the spinal accessory nerve ; the dyspnoea of asthma 
depends on the spasmodic contraction of these fibres, the partial obliteration 
of the air-passages requiring violent respiratory efforts to secure the necessary 
introduction of air ; in this constriction, the larynx is involved, as evinced by 
the whistling of the inspirations; the non-introduction of air into the pulmo- 
nary vesicles accounts also for the diminution or even absence of the respira- 
tory murmur. 

One of the consequences of this dyspnoea is emphysema, which in its turn 
becomes a cause of dyspnoea, or a secondary symptomatic asthma. This last 
condition being permanent, symptomatic may be distinguished from idiopathic 
asthma, and from angina, by the difficulty of respiration in the intervals of 
the paroxysms. The air, imprisoned, as it were, in the contracted bronchi and 
vesicles, is expanded by the heat, and dilates them ; hence emphysema. 

If there be paralysis, instead of spasm, of the spinal accessory, emphysema 
may be the consequence. The lungs not being able to expel the vitiated air 
completely, the vesicles become distended ; thus, emphysema is often found in 
angina pectoris. 

In many cases of asthma and spasmodic cough, the par vagum has been 
found inflamed. (See Longet, vol. ii. p. 365.) 

The irritation of the spinal accessory is frequently communicated to the 
other respiratory nerves and their anastomoses. This is seen in recorded cases 
of angina (see Dr. Blackall, and the case of the captain^bove alluded to), 
where irregular twitchings occurred in the pectoral and deltoid muscles. 
These may occur with or without pain; but the irritation of the motor fila- 
ments would be very likely communicated to the sensitive filaments, and vice 
versa. In either case, we should have a combination of neuralgia with spasm, 
or a painful cramp. The occurrence of neuralgic symptoms in the intervals, 
or during the continuance of, asthma is not uncommon. 



1850.] Kneeland on Angina Pectoris. 61 

Those authors who consider angina pectoris as depending on the organic 
lesions of the heart and its vessels so often found with it^ of course regard it 
as a disease necessarily fatal. As we consider it a nervous disease^ we should 
make a different prognosis^ particularly if the affection be not of long stand- 
ing, and the patient be young and healthy. We think it an error to suppose 
it peculiar to advanced age ; it may occur, like other neuralgia and rheumatism, 
at all ages, and in such persons may be cured by similar remedies. There 
are, even among old people, several undoubted cases of cure, recorded in the 
Dictionaries of Medicine. Allowing for inaccuracies of diagnosis, we may 
find Laennec not very far from the truth, when he says : ^^ Angina pectoris, in 
a light or moderate degree, is an affection extremely common, and exists very 
often in persons who have neither an organic disease of the heart nor of the 
great vessels. I have seen many who have had very violent attacks, but of 
short duration, who have recovered" {^Auscult., torn. ii. p. 747). If the disease 
be neuralgic, recovery may be complete without any organic change. If it be 
rheumatic, recovery might leave behind it a predisposition to cardiac disease, 
so often found in connection with it. Even supposing the disease to arise 
from a complete disorganization of one pneumogastric, life may be consider- 
ably prolonged, and good health enjoyed — the nervous communication being 
kept up by the anastomosis between the superior and inferior laryngeal, which 
has been found one-third the size of the cervical par vagum. (See Longet^ 
tom. ii. p. 356.) 

Treatment in this disease is generally considered of no avail ; at any rate, 
as only palliating the symptoms : but, if we get clearer ideas of its nature, our 
treatment ought to be more rational, and therefore more successful. 

During a paroxysm, after all evident exciting causes have been removed, 
the treatment will be active in proportion to the strength of the patient and 
the violence of the symptoms. If there is reason to suspect an effusion of 
blood into the medulla oblongata, as there might have been in our case, active 
depletion would be indicated, as recommended by Parry and Burns, even in 
plethoric individuals, by venesection, leeches, or cupping over the spine. What- 
ever the supposed cause, opiates, antispasmodics, and carminatives are usually 
given, with ether, ammonia, or other stimulants, if there be coldness and faint- 
ness. To these would be added counter-irritation by blisters, but especially by 
dry cupping over the spine. Besides these, and others, which would occur to 
every one, we would advise the inhalation of oxygen, as recommended by Dr. 
Robert Reid, in the Dublin Transactions for 1817. We have seen that the 
principal danger is from insufficient aeration of the blood ; so that, by such in- 
halation, the immediate symptoms of suffocation might be relieved, and suffi- 
cient time gained for the removal of the exciting cause. 

During the intervals, in addition to the numerous precautions and remedies 
detailed in the books, we would suggest the preventive and curative treatment 
of neuralgia and rheumatism, whenever these may seem to have any connec- 
tion with the past history of the symptoms. 
No. XXXyn.— January, 1850. 5 



62 Kneeland on Angina Pectoris. [Jan] 

We thinkj however^ the great remedy must be electricity , which, according 
to Matteucci (quoted by Dr. W. F. Channing, Medical Application of Elec- 
tricity, p. 10), differs from all other nervous stimulants in that it excites sensa- 
tion at one time, and contraction at another, according to the direction in 
which it traverses a nerve; which alone has the power of increasing or dimin- 
ishing the excitability of a nerve, according to the direction in which it is 
made to flow; which has the power of awakening the excitability of a nerve, 
after all other stimulants have ceased to act. The form to be preferred 
depends on whether we wish merely to stimulate the filaments of the par 
vagum in the organs to which they are distributed, or to produce structural 
change in the medulla oblongata. In the former, electro-magnetism would be 
indicated ; in the latter, the uninterrupted current of the battery. If electro- 
magnetism should fail in the first, the battery should be tried, as this has 
been found beneficial in paralysis without li;ructural change, where the first 
has failed. Without careful diagnosis, therefore, harm instead of good might 
ensue. By stimulating the paralyzed spinal accessory, not only is the vitiated 
air expelled from the lungs, but oxygen is admitted, which might also be in- 
creased by inhalation of this gas ; so that these two remedies might be advan- 
tageously combined. A current in the direction of the nervous ramifications 
would stimulate directly the motor filaments ; in the opposite direction, the 
sensitive filaments : but, in the mingled filaments of the par vagum, reflex 
action will often cause similar effects, in whichever direction the current is 
passed. However, in cases of spinal irritation or inflammation, it would be 
improper to send a current towards the medulla. 

From the favourable results of electricity in asthma, as detailed by Wilson 
Philip, we may expect similar advantages in angina pectoris. Laennec says 
"he has perceived great benefit from the application of two magnetized plates, 
one before and one behind." A galvanic current from a platinum and zinc 
plate, thus worn, might be of advantage. Dr. Channing [op. cit, p. 124) 
says, "the handles employed would preferably be the surface handles, covered 
with leather. The current should not be excessive. Subjection of the sys- 
tem to the general influence of galvanism, by the daily use of the cylinder 
conductors, one held in each hand, might also be advantageous." From the 
back of the neck to the epigastrium would probably be a good direction for 
the current. 

In conclusion, we may deduce the following results from what has been 
above written : — 

1. From the symptoms and morbid appearances, angina pectoris is not a 
disease of the lungs, heart and its vessels, or stomach; but an affection of the 
nerves supplying these organs. 

2. Anatomy, physiology, and pathology would lead us to place the seat of 
angina pectoris in the par vagum, and not in the sympathetic system of nerves. 

3. Like other nerves, the par vagum may be affected with neuralgia and 
rheumatism; with inflammation; it may be compressed by morbid growths ; its 



1850.] Bowditch on Hemorrhage from, ilie Umbilicus, 63 

spinal origin may be compromised by hemorrhage^ accidental wounds^ and 
various irritations — all of which may cause the symptoms of angina pectoris. 

4. Angina pectoris and asthma are intimately related: the former being 
an affection more especially of the sensitive filaments of the par vagum ; and 
the latter an affection of its motor filaments. Both are generally more or less 
combined in the same case. 

5. Angina pectoris is a disease not necessarily fatal^ especially in young 
persons, if accurately diagnosticated, and properly treated. 

6. In addition to the remedies of the books, special attention should be 
given to the inhalation of oxygen, and to the use of electricity. 

7. In cases of angina pectoris, attention should be directed to, the exami- 
nation of the par vagum, from its origin to its terminations, which, doubtless, 
on careful examination, will exhibit lesions sufficient to account for a fatal 
result. 



Art. III. — On Hemorrhage from the UmhlUcuSy in, N'em-hom Children; vnth 
Cases. By Henry I. Bowditch, one of the Physicians of Massachusetts 
General Hospital. (Read before the Boston Society for Observation in 
Medicine and the Collateral Sciences, July 2d, 1849.) 

Mrs. Y. Z., a stout, healthy young woman, living in Boston, in easy cir- 
cumstances, and who had gone through her pregnancy without any peculiar 
symptoms, was confined with her first child Aug. 17th, 1838. Labour 
natural, and placenta removed without difficulty. The child was a female, and 
seemed perfectly well formed, and for several days after birth appeared quite 
healthy. The umbilical cord fell off on the third day ; and from that time 
until the fourteenth, when I was consulted, the child continued to thrive, and 
to be in every respect normal, except that there was a slight oozing occasion- 
ally from the umbilicus, with the formation of a small coagulum. On the 
morning of the fourteenth day (Sept. 1st), I was summoned, as the hemor- 
rhage had been more manifest. By compression, the flowing was checked, 
and none occurred from 4 P. M. that day, until 4 A. M. of the fifteenth day. 
It then commenced anew, and I was called at 8 A. M. On examination of the 
umbilicus, it looked healthy. There was no distinct opening whence the 
blood issued ; but, from the corrugated centre of the umbilical depression, 
there was a constant, slight oozing of thin, arterial-looking blood. A compress 
of lint restrained it during the forenoon, and, subsequently, spunk was super- 
added. But the movements of the child displacing the bandage, the hemor- 
rhage increased. A dossil of lint, sustained by the finger of an attendant, 
effectually arrested the flow, until 7 P. M., when I perceived that the lint 
was becoming gradually soaked with blood and raised from its bed, and that a 
still greater disposition to flow was manifested. Slight astringents, as sulphate 
of copper and of zinc, were likewise used during the forenoon. 

Directions were given to have the patient kept constantly in the nurse's lap, 
and the finger of an assistant to be applied all the time. At 4 A. M. of the 
sixteenth day, the hemorrhage increasing in spite of any amount of astringent 



64 Bowditcli on Hemorrhage from the Umhiltcus. [Jan' 

application, T used very freely tlie solid nitrate of silver, without the least 
eifect, except apparently to augment the hemorrhage. Early this morning, a 
consultation was held with Dr. Hayward ; and it v/as decided to pass a double 
ligature through the umbilicus and surrounding integuments, and enclose the 
whole. By this means, the hemorrhage was arrested three or four hours only, 
when oozing again began, and an ineffectual attempt was made to apply an- 
other ligature. Another operation was needed. It was performed at 2 P. M., 
by means of two needles at right angles to each other, passed through the 
skin, ^ to which ligatures were applied, as in hare lip. A circle of the integu- 
ments three-quarters of a^ inch in diameter was thus enclosed. 

Entire success seemed to be the result. No hemorrhage followed. Up to 
this period, the child continued strong and well in its general habit of body. 
It had become somewhat pale, but by no means bloodless, about its lips. It 
nursed well, and the dejections were natural. Its limbs and abdomen were in 
perpetual motion. 

Sept. 4:th. (Seventeenth day since birth, and third of hemorrhage.) Very 
comfortable; aspect better; lips of rosy hue. Every circumstance seems fa- 
vourable, except that the compresses over umbilicus are slightly stained with 
blood, and a little blood appears in the dejections. Patient lies quietly, and 
nurses strongly. 

Abdomen to be watched constantly ; patient to continue in lap of attendant. 

Sept. bth. (Eighteenth day from birth, fourth of hemorrhage.) Restless 
three hours during the night; compresses more bloody; slight oozing from 
under them. Abdomen distended; dej. rather greenish. Patient appears 
occasionally to have slight colics, but lies quiet most of the time. Inside of 
mouth red ; nowhere is blood seen oozing, but sugar teat used by patient is 
stained with it. 01. ricini 51; paregoric three drops after dej., and to be 
repeated if needed. 

Sept. Qth. (Nineteenth day since birth, fifth of hemorrhage.) Nursed well 
during night; four dej. bloody during night, one of them clotted, but gene- 
rally they were thin and rather copious. Skin paler. On inside of first joint 
of right thumb is a slight ecchymosis. During this day, several bloody dej. 
took place, and from eighteen to twenty drops of paregoric were taken, under 
the influence of which the patient lay quiet. Constant oozing took place from 
umbilicus, which was covered with a mass of clotted blood and linen cloths. 
At 10 P. M., the pulse was slower, compressible under the slightest effort. 

Sept. 7th. (Twentieth from birth, sixth of hemorrhage.) Face more 
bloodless, sallow; bleeding still continues; dej. still bloody. Occasional 
paroxysms, as of colic; pulse 98. At 1 P. M., death took place, the paroxysms 
above named having occurred several times. No autopsy was made. 

In April, 1840, and September, 1843, the same lady was confined with 
healthy boys, who are now alive and well, without tendency to hemorrhage. 

But Jan. 30th, 1845, she had another child (a male), who died of bleeding 
from umbilicus as the first one had died. The details of this case are as 
follows : The patient had been better during this pregnancy than during the 
previous ones. About the period of the third month, she had some hemor- 
rhagic show, and labour pains, which were relieved ; and she completed her full 
term. Labour began early in the evening of January 30th, 1845. At 10 
P. M., I saw her, and found she had regular pains. Mouth of womb dilated, 
and bag of waters protruding, head presenting. In an hour, I left her, the 
birth having been completed, and the placenta having come away, without any 
special trouble. 

No unusual hemorrhage then, or subsequently, from mother, and she con- 



1850.] Bowditch on Hemorrhage from the Umbilicus. 65 

tinued well, except that she suffered with after-pains for two or three days. 
The milk came freely about the third day. 

The child was plump and hearty, and rather above the medium size. It 
appeared well for several days, except that about the fifth it suffered somewhat, 
apparently from colics. However, it nursed and slept well. The bowels were 
never very freely opened, but discharged whitish, almost clay-coloured dejec- 
tions, never meconium or anything yellow. The urine, on the contrary, was at 
times of a deep orange colour, as if strongly impregnated with bile. Slight 
icterus existed for a few days, but not more than is very commonly seen in 
children who are apparently healthy. The cord was smaller than usual, and 
caused no trouble at time of labour. It separated on the fifth day, and the 
umbilicus looked healthy. It continued to discharge a little purulent, and 
occasionally a little bloody fluid, until 8th, and from that time until 4 P. M. of 
the 10th, no stain was perceived on the compress. 

At that time, I was called, as a slight oozing of blood had been perceived. 
I examined the interior of the umbilical aperture, and could perceive a slight 
spongy appearance, but nothing otherwise peculiar, and from this point the 
blood oozed as it often exudes from the gums. On the morning of this (10th) 
daj^, the nurse, while washing the child, perceived a small "black and blue^' 
spot just at the edge of the left scapula, about half an inch in diameter, and 
hard, as from extravasation, under it. I prescribed gum Arabic and a dossil of 
lint to the umbilicus, and very little hemorrhage occurred during the night. 

Feb. Wth. (Eleventh day of life.) Consultation with Dr. James Jackson ; 
we filled the cavity of umbilicus with tannin, and ordered a piece of spunk 
to be kept constantly pressed upon it. Soon after this application, the blood 
flowed in a small stream over the abdomen. 

This free hemorrhage, occasionally slightly restrained by compression, con- 
tinued through the day and night, so that several compresses, of four and 
eight thicknesses of linen, were drenched. Two more spots of extravasation, 
similar to that above spoken of, appeared this day on the right elbow. When 
I saw them, they, with the first one, had increased somewhat in size ; but they 
were not very manifest even then. By advice of Dr. Jackson, I gave calomel, 
one grain in two doses, to be followed by 3^ ^l- ricin. I also prescribed 
sulphate of soda' in grain doses every hour; and a new nurse was procured. 
None of these means restrained the bleeding; and, at 9 A. M., Feb. 12th 
(twelfth day of life, about forty-eight hours from commencement of hemor- 
rhage), Dr. Hayward saw the child. At that time, it had much strength, 
though it was paler, and of a somewhat yellowish-livid colour. There had 
been two dejections of the same character, and, perhaps, a little greenish. In 
one, there had been a streak of blood. Actual cautery, by means of a large 
knitting-needle, was performed. The interior of the umbilical tube was 
thoroughly burned, after it had been pulled up and opened as much as possi- 
ble, so as to bring the parts into full view. The patient suffered very little 
from the operation; but a mixture of laudanum, 51 to water ^i, was directed 
as a local application, and paregoric, five drops, to be given internally, if the 
pain was severe. A slight oozing of blood began immediately after the cau- 
terization. This continued very free, and augmented during the day, though 
less than before the operation. No coagula, or tendency to coagulate, was 
shown. At 7 P. M., child still strong, kicking, &c., with vigour; pulse quite 
rapid, tolerably full; redness of lips and integuments, and generally patient; 
lies quiet under influence of opiate; some thirst; dej. as before. Prognosis 
in consultation with Dr. Jackson, Hayward and mj^self Inevitable death. I 
was in favour of trying transfusion, and arrangements were made for that pur- 



66 Bowditch on Hemorrhage from the UmhiUcus. [Jan. 

pose; but, on further consultation with the surgeon, it was deemed wiser 
not to try it. Feb. 13 (thirteenth of life, third of hemorrhage). Bleeding 
very free during the night previous j child inclined to sleep ; in no suffering, 
but paler; pulse one hundred and fifty. About 10 A. M. there was a mo- 
mentary partial cessation of the hemorrhage, and one dejection, slightly yel- 
low, occurred; urine still deeply tinged. At 12, bleeding anew, and the 
patient died at 7| A. M. of Feb. 14, just four days after the first ecchymosed 
spot appeared. 

Autopsy twenty-six hours afterwards. — General sallowness of the surface, 
except the hands, which were pale, almost white, and nails livid ; right elbow 
very livid and swollen, evidently with extravasated blood; similar aspect of 
left scapula. Abdomen contracted; umbilicus not remarkable. Its edges 
were a little moistened, the eschar adhering only at one or two points. No 
evident opening of any blood-vessel; muscles very pale, and little adipose 
matter. 

Respiratory system. — Lungs exceedingly pale, without adhesions ; posterior 
lobes somewhat reddened; a small spot of extravasated blood under the 
pleura covering the left. Both crepitated and appeared healthy, as did the 
bronchial glands. Pleurae costales healthy. 

The thymus gland projected downward over the heart; it was white, 
seemed healthy, and contained no milky fluid. 

Circulatory system. — Pericardium contained about Ji of yellow fluid. It 
was healthy. 

Heart medium size ; auricles shrunken and containing no blood, only a 
little being pressed up from vena cava ascendens. No coagula. Yalves and 
membranes, carefully examined, perfectly normal. Aorta and pulmonary 
artery collapsed. Hypogastric arteries were somewhat thickened, hardened, 
and purplish, for an inch from umbilicus, but no air could be blown through 
them or the umbilical vein, and their interiors seemed healthy. No coagula 
in either. 

Digestive system. — Stomach small, and contained an adhesive white mucus. 
Its mucous membrane, with that of the whole track of intestinal canal, was 
pale, smooth, and healthy. No extravasation ; no blood in contents, which 
last were small in quantity ; slightly yellow near stomach ; pale, white, below. 
Large intestines contracted; contents, only a little undigested food. Mesen- 
teric glands small and normal. Liver quite large, filling epigastrium, and 
extending down to umbilicus ; it was of a yellowish colour externally, quite 
flaccid in consistence, and, on incision, was found to be wholly altered in 
structure. None of the red parts were perceptible, and the cut surface 
looked very like the interior of the colon, when covered with a soft yellow 
feces. By the slightest touch of the scalpel, I could raise a quantity of simi- 
lar matter. It adhered to and stained a cloth, like feces. Gall hladder small, 
contracted, and contained no bile. Its interior was white and smooth. The 
ducts were pervious, and contained a little yellow matter. 

Spleen entirely normal in size and consistence, and red as usual. Pancreas 
healthy; so likewise were the renal capsules. Both Iddneys of usual size, and in- 
ternally looked well, except that all the mammillary processes were stained with 
a kind of pigment running in diizection of the fibres; at first sight, these looked 
like minute granules, but they were not gritty; most distinct towards the ter- 
minations of the processes. This appearance is frequently seen in the kidneys 
of very young children ; it was probably urate of ammonia. Urine in pelves 
turbid with the same, making a sort of brickdust infusion. Ureters distended 
and thin. Bladder of medium size^ and containing some urine; appeared well. 



1850.] Bowditch on Hemorrhage from the UmhiUcus. 67 

ResumS. — In these cases^ both children died of hemorrhage from the navel 
(on the twentieth and fourteenth days after birth). They were of both sexes; 
while males, according to authors upon the hemorrhagic tendency, are more 
liable than females. In both cases, the cord came off quite well, and without 
external injury ; one on the 3d, the other on the 5th day after the hemor- 
rhage commenced. In both, the parts seemed entirely cured, and presented 
no discharge for several days before the fatal oozing took place. In both, all 
local applications seemed, in a very short time, to excite rather than to check 
the disease. In both, very violent surgical operations were resorted to with- 
out the least benefit. Death took place in one on the 3d, in the other on the 
6th day after attack. One had white dej. from bis'th; both had purpuric 
extravasations and bloody dej. at last. At the autopsy of one, disease of 
liver and non-coagulated blood were found ; no opening or apparent disease 
about the navel or vessels leading thereto was found. 

Although these two cases have occurred in my own practice, I regard this 
as a very rare disease, and my reasons are as follows : — ■ 

On consulting several works on the G-eneral Practice of Medicine, which 
I have been able readily to procure, I find no mention made of it in the fol- 
lowing: viz., Cyclopaedia and Library of Practical Medicine; Grood's, Wat- 
son's, Copland's, and Wood's Practice of Physic. 2d. In the works on Mid- 
wifery, it is ignored by Yelpeau, Maygrier, Cazeau, Levret, Gouch, Collins, 
Murphy, Eamsbotham, Burns, Tucker, Dewees, and Meigs. On the contrary, 
Chailly, Hutin, and Baudelocque speak of it as of trivial moment, and do not 
even hint at its occasional fatality. 3d. In those works devoted to diseases 
of children, Bouchut, Rilliet and Barthez, Valleix, Stewart, and Condie do 
not mention the fact. Evanson and Maunsell allude to it as occurring from 
insufficient ligature of the cord, which was evidently not our case. Underwood 
alone makes two classes. In one, after the cord has come off, a fungus arises, 
which sometimes bleeds for months. In the other, there is a bad condition of 
the system, and bleeding occurs where the umbilicus has been apparently well 
healed- In neither does he regard it necessary to resort to very violent 
remedies- 

From this want of data in those works devoted to Greneral Practice, Mid- 
wifery, and Diseases of Children, it is evident that the profession at large has 
paid but little attention to this grave affection. I shall, in a brief manner, 
allude to similar cases observed here, and those found recorded in Medical 
Journals to which I have had access. I have examined all the British and 
Foreign Medical Reviews, the first fifteen volumes of American Medical 
Journal, Medical Magazine, and three first volumes of Medical Examiner, and 
all the journals recently received by this society; but in none can I find any 
record of cases exactly similar, although there are some cases of hemorrhagic 
diathesis in adults to which our cases are undoubtedly allied. 

Dr. West, in his able Lectures on Diseases of Children, originally published 
in London Medical Gazette, alludes to three cases of fatal icterus of children, 



68 Bowditch on Hemorrhage from the Umhilicus. [Jan. 

published by Dr. A. B. Campbell in the JSforthern Journal of Med. for August, 
1844. To this paper I have been unable to procure access. I allude to it 
noW; because Dr. West speaks of fatal hemorrhage from the umbilicus a fort- 
night after birth as being liable to take place in these cases, and because in 
one of ours certainly, and in some of Dr. Homans', to which I shall allude 
hereafter, icterus existed. Dr. W. remarks that the cases are rare, and that 
he never met with one. In connection with these suggestions by Dr. West, 
the fact of hemorrhage having occurred not unfrequently in cases of disease 
of liver, in adults in this city, becomes interesting. 

Dr. Radford {Edin. Med. and Surg. Journ., July, 1832, page 520, vol. 
xi, 3Ied. Surg. Journ., 1832), has a paper on the subject, in which he 
makes two divisions: namely, 1st, hemorrhage from the cord from bad tying; 
disease of funis, such as ossification or varicose state of the vessels ; 2d, bleed- 
ing from the navel, owing to incomplete closure of the vessels. Bleeding in 
this case, if from the veins, is usually fatal, and the only resource is, cutting 
down and tying up the vessels, as other treatment fails. 

I have endeavoured to obtain records of twelve cases that have occurred in 
Boston, seen by Drs. Homans, Jackson, Hayward, and Dyer. Of five, I have 
gained some imperfect details. Of the others. Dr. Homans, who has collected 
them, has given me a few items.* I will give a brief analysis of their main 
facts. 

Hereditary predisposition. — In only one case is notice taken of any predis- 
position. This, however, evidently does not give the exact ratio, the records, 
in this particular, being poor. In one case, the mother was represented as 
being of a scrofulous disposition. 

Period after hirth at which hemorrhage hegan. — In the eleven cases in 
which this was noticed, its average was seven and three quarter days before 
hemorrhage began. The earliest day was the third ; the latest was the eight- 
eenth. 

Period, after falling of the cords, at which hemorrhage hegan. — In three of 
the cases was this mentioned, and the average time was the eighth day. Latest, 
eleven days ; earliest, five days. 

How soon did death happen after the commencement of hemorrhage ? — This 
is named in nine cases. In one, it occurred in ^' a few hours.^^ Of the eight 
others, three and seven-ninths of a day was the average ; seven days being 
the highest, and one day the lowest. 

* These cases have been published in the Boston Medical and Surgical Journal^ July 11, 
1849, subsequently to the preparation of this paper. Of the five who bled after the separa- 
tion of the cord, three died. Of the four, who had hemorrhage from other parts besides 
the cord, three died. In three, icterus existed ; and death occurred in two of them. 

I will take this occasion to remark, that my attention has been drawn to the fact that 
Dr. Marsh has published, in the New Jersey Medical Reporter, two cases; and Dr. Cook, in 
the New York Annalist, one case of hemorrhage after the removal of the cord. All three 
l^roved fatal, and all were complicated with jaundice. 



1850.] Bowditch on Hemorrhage from the Umhilicus. 69. 

Character of the hemorrhage from umhilicus.' — Mentioned in six cases. In 
one, it was sudden, and with a sudden return after being stopped, and death 
took place in a few hours. In all the rest, there was more or less effect from 
the treatment, the blood being checked in its course — usually, however, only 
for a short time. 

Was there any hleeding from other parts besides the umhilicusl — A tumour 
on the scalp appeared in one. In two more, some purpuric eruption ; and 
bloody dejections in six. 

Jaundice is a very common accompaniment of this hemorrhage, and is de- 
cidedly an unfavourable, though not a fatal, symptom. 

Finally. — One died comatose ; but the usual termination of life was, appa- 
rently, from prostration, induced by the hemorrhage. 

From these investigations, and other facts not noticed in this paper, we 
may infer, I think, that there are five classes of hemorrhage from the um- 
bilicus. 

1st. A bleeding occurs soon after labour. This is generally owing either 
to insufficient care in applying the ligature to the cord, or to a contraction of 
the cord, which, at the time of being tied, is large; and the fluids, subse- 
quently exuding, allow a relaxation of the ligature. This, if noticed early, 
can be easily restrained by a new string. 

2d. I find one case recorded by Dr. Hill [Lond. Med. Gaz., from Dublin 
Med. Press, vol. Hi, p. 556), in which great hemorrhage occurred, in conse- 
quence of a practitioner having forcibly removed the cord, from fear that ery- 
sipelas would ensue, if it were allowed to remain. It is to be hoped that few 
cases of this kind will ever occur. 

3d. There is another, of which we have alluded to one specimen, given in 
Dr. Jackson's notes of a case treated by Dr. Hay ward. The bleeding began 
on the third day from the removal of the cord, and, notwithstanding every 
effort, death occurred in twenty-four hours. In this case, there was probably 
an imperfect closure of the vessels from non-coagulation of the blood. 

4th. The largest class of serious bleeding is like those reported by me. 
In these, the funis drops off, and usually nothing abnormal is observed, or, at 
most, only a delicate sponginess in the umbilicus. After three or four days, 
an oozing commences, which either increases with every application, or, per- 
haps, is slightly checked by astringents, &c.; but it almost always proves 
fatal ; and the patients, before death, become perfectly blanched. In these 
cases, it is very common to observe an alteration in the functions and struc- 
ture of the liver; the dejections being non-bilious, and, at the post-mortem 
examinations, disease of the hepatic structure, or of the ducts, being observed. 

5th. Finally, we have the really hereditary hemorrhagic tendency. The 
blood, in these cases, oozes from the gums, intestines, under the skin, &c. 
There are few cases on record of this class in new-born children, unless we 
consider our own cases and the class of hemorrhage, described as our fourth 



70 Bowditch on Hemorrhage from the Umbilicus. [Jan. 

species, to be such ; but there are numerous examples of it among adults,* in 
whom, however, the navel seems to have healed perfectly, soon after birth. 

Prognosis. — This evidently will vary with the cause of the hemorrhage. 
For example, an insufficient ligature may be made stronger. A case like that 
of our second class, viz., an accidental tearing away of the cord, would be 
much more subject to remedies than either of the last three kinds, namely, an 
insufficient closure of the vessels ; a fungus of the navel, connected, as it usu- 
ally is, with disease of the liver; and finally, the hemorrhagic diathesis. The 
first two, under judicious treatment, will undoubtedly do well. In the third, 
if the vessels can be cut down upon and tied up, some hope may be gained of 
safety. In fungus and the hemorrhagic diathesis, especially when there is 
any mark of hepatic disease, much less chance of recovery is afforded. 

Treatment. — The treatment, of course, must vary with the class. In rela- 
tion to the first class, viz., that in which" there is bleeding from the cord, 
owing to its contraction and the subsequent loosening of the ligature, it may 
be remarked that this will rarely happen if the practitioner, at the time of 
labour, takes sufficient precautions. He should always, before leaving the 
room, ex:amine the cord a second, and, if need be, a third time ; and, if it has 
been large, and seems disposed to contract, so as to allow of any oozing, a new 
ligature should be applied. 

In the second class, where injury is produced by the violent removal of the 
cord, use should be made of caustic ; or, still better, of plaster of Paris poured 
in a liquid state on the part, so that a plug will be formed, on its becoming 
hard, in all the minutest crevices, and even in the mouths of the bleeding 
vessel. This should be retained for three or four days, and success will pro- 
bably be the result. 

In the third class, it will be difficult to decide whether the bleeding is 
owing to the open mouths of deep-seated vessels, or to an original hemor- 
rhagic tendency. If, however, there be no hereditary tendency, and if there 
be no marks of hepatic lesion, we may use styptics of various kinds : tannin, 
collodion, sulphate of zinc, sulphate of copper, and caustics. The best treat- 
ment, however, would undoubtedly be that advised by Dr. Kadford, of Dub- 
lin, namely, to cut down and tie up the bleeding mouths. In order to do this, 
we should endeavour to decide from which the hemorrhage proceeds, in order 
to prevent the necessity of too much cutting. 

In the fourth class, where hemorrhage from the umbilicus, without evident 
cause, takes place, which can be only partially restrained by astringents, and in 
which there is hepatic lesion, I believe that very little hope may be anticipated 
of affording relief. At times, however, a slight oozing may continue for 
months, and the patient finally get well. But this is uncommon. In our cases, 
all astringents and caustic compresses seemed rather to stimulate than 

* Vide Brit, and For, Med. Review, vol. ix., 247. i 

« Am. Journal of the Medical Sciences (Pliil.) Vol. V., 252, 488 ; Vol. IX. 
" Med, Magazine (Boston), vol. i., 553, 



1850.] ParkmaD^ Extracts from Soc. for Med. Im/provement. ' 71 

diminisli the hemorrliage. Even the plaster of Paris, and ligature^ and actual 
cautery, are of no avail. The oozing, checked for awhile, returns until death. 
Some have advised internal remedies in these cases, with the idea of correct- 
ing the fluidity of the blood. For that purpose, I used sulph. soda, as recom- 
mended in the British and Foreign Medical Revieiv, ix. 247. If, however, 
Simon's view is correct, that icteric blood, while it possesses less fibrin, has 
more salts and albumen, than usual, we should not use sulphate of soda in cases 
where icterus is found. Transfusion has been suggested ; and I regret that 
it was not tried in our cases : but the older surgeons had no faith in the 
remedy, and the younger preferred not to use it. To me it seemed the only 
means left for preserving life. 

In the fifth class, where there is a natural predisposition to hemorrhage, 
what can be done ? If the same applications may be made to the child as 
those made to the adult, the actual cautery is undoubtedly the best styptic. 
The late Dr. Hale, of this city, used to relate to me the case of a man who 
always carried a nail in his pocket, in order that he might cauterize any part 
of his body that was bleeding. But our cases prove but little in favour of 
this method. The cautery did not, in fact, check the hemorrhage one hour. 
Transfusion I should have less fiiith in than in the previous case. A ques- 
tion arises, whether the mother should nurse the child. I think not ; still, 
when we bear in mind the fact that, in many cases, the hemorrhagic tendency 
does not show itself in the mother, but in the grandparents, we can hope but 
little from a strange nurse. 



Art. IV. — Extracts from the Records of the Boston Society for Medical 
Improvement. By Samuel Parkman, M. D., Secretary. 

May 2Sth, 1849. Fracture of the Face. — Dr. Cotting had lately picked up 
in the street a man who had been run over by the wheel of his own cart ; 
blood was being profusely discharged from the nose and mouth. He found a 
fracture of the lower jaw on one side, and a dislocation on the other; and a 
separation of the whole face from the base of the skull. The man is now doing 
well, and the fracture healing without much deformity. Dr. J. M. Warren 
had seen a similar case in an old lady, who, falling into an open cellar, struck 
upon the face ; the face was driven backwards, and the respiration much 
obstructed from the compression, and the blood from the lacerated soft parts. 
The fragments wel-e replaced, and the patient did well. 

Death from Laudanum in Three- Quarters of an Hour. — Dr. Coale had a 
memorandum of a case where death followed the ingestion of the poison after 



72 . Parkman, Extracts from Soc. for Med. Improvement. [Jan. 

an interval that could not have been longer than that above stated. Dr. C. 
desired to mention this case in connection with one reported some time since 
by Dr. Lyman^ where the time was equally short. 

Rupture of the Lung. Dr. Strong. — A boy was injured on a railroad, 
it being doubtful whether the wheel of the car actually passed over him or 
not. There was no external injury ; the boy remained in a state of collapse, 
and died at the expiration of about three hours. At the autopsy, no fracture 
of the ribs was discovered ; but the pleural cavity contained a large quantity 
of blood, proceeding from a rupture of the lower part of the lung, presenting 
the appearance as if cut with a knife. 

- June 10th. Trepanning for an Old Depression causing Idiocy. Dr. J. M. 
Warren. — A girl, ten years of age, during infancy, was struck upon the 
top of the head. And, although the corporeal faculties had increased nor- 
mally, there had been little, if any, manifestation of intelligence. The child 
recognized imperfectly her parents, but was unable to articulate, emitting 
only a species of howl ; she was also subject to constant and violent convul- 
sions. On examination, there was found a longitudinal depression, three to 
four inches in length by one in width across the head, just behind the coronal 
suture. At the request of the parents, and with the full understanding of 
the danger, it was decided to remove the depressed portion. This was done 
with two crowns of the trepan ; the opening being joined by cutting out the 
intermediate piece with a Hey's saw. The child lived nine days — for the 
first six days doing well. She died from a bleeding from the longitudinal 
sinus, which ruptul'ed after some sudden and violent movement made by the 
patient in bed. The father thought there was an appreciable increase of the 
amount of intelligence after the operation, and it was obvious to every one 
that she took cognizance of persons and things about her in a way she had 
never done before. 

Malignant Disease supervening on a Non-Malignant Groiuth. — Dr. Bethune 
said he had several times alluded to the possibility of a tumour, or other 
simple growth, remaining for a long time in that state, and then suddenly 
taking on malignant action; he had lately had a case in point. A man, 
sixty-five years of age, had had a simple membranous tumour of the conjunc- 
tiva for sixteen years ; lately, this little tumour had increased in size, becom- 
ing hard, purplish, and painful, presenting signs of malignant disease ; which 
character was fully established by dissection of the globe after its removal. 

25^/i. Method of Arresting Bleeding from Alveolus. — Dr. Homans exhibited 
a wax impression of an alveolus, from which a tooth had been extracted. 
The bleeding was very obstinate ; but was complete!}^ arrested by plugging 
the cavity v/ith wax, softened in spirits of turpentine. 



1850.] ParkmaH; Extracts from Soc. for Med. Improvement. 73 

Method of Extracting Foreign Bodies from Nostrils. — Dr. Honians, for 
many years, had practiced the following : Closing the nostril, which is free, 
he blows forcibly with his own mouth into the mouth of the patient, and the 
result is the discharge of the body. 

He stated that, in no case where such substance completely obstructed the 
passage, as beans, peas, kernels of corn, &c., had this method failed of suc- 
cess ; but, when the substance introduced was so shaped as not entirely to 
obstruct the passage, as a button, the air blown in might pass through, and 
not remove, the body. 

July 9th. Ligaiure of External Iliac Artery. — Dr. S. Parkman exhibited 
the specimen, from a patient in the Boston Lunatic Asylum, under \hQ care 
of Dr. Stedman. The patient, a lunatic, was stabbed by another lunatic with 
a carving knife, on the outside of the thigh, just below the trochanter. The 
bleeding was so profuse, the knife having gone in front of the bone in the 
direction of the artery, that the femoral artery was tied by Dr. Stedman as it 
passes from under Poupart's ligament. Two weeks after the ligature sepa- 
rated, bleeding took place at the point where the artery was tied, and it 
was deemed advisable to tie the external iliac artery. After two v/eeks, the 
patient died ; the wound not having united, and gangrene of the extremity 
having taken place. The autopsy showed the parts around the artery undis- 
turbed, with the ligature still in situ ; a soft coagulum was just above the 
ligature, extending to the iliac bifurcation, but forming no satisfactory plug, 
and bleeding would have followed the separation of the ligature. 

Bleeding from the Ear — its Origin in Fracture of the Base of the Skull, 
and its Prognostic Value. — Dr. S. Parkman said he had lately had a case 
relative to the discussion upon this subject, several evenings since : a frac- 
ture, extending across the whole base through the right petrous portion of 
temporal bone, and traversing the right lateral sinus, near its termination in 
the jugular vein. As regards the value of this as a prognostic sign. Dr. P. 
said it was plain to see that it was not impossible that fracture of the base 
should terminate favourably ; the bleeding being external instead of internal, 
and compression being thus avoided. Bleeding from the ear is, therefore, not 
necessarily a fatal sign. 

August lith. Bean in the Trachea. — Dr. S. Parkman gave the particulars 
of a case to which he was called after death. A child, of eleven months, 
was supposed to have swallowed a bean on a Saturday; had several fits of 
dyspnoea, in none of which, however, was it seen by its physician, who uni- 
formly found it free from pulmonary symptoms. On Monday, in an access, 
it ceased to breathe. The trachea being opened after death, a bean, swollen 
to double its size, was extracted. In view of the great swelling of vegetable 
bodies, Dr. P. thought a patient should not be left without watching, as the 



74 Parkman, Extracts from Soc. for Med. Improvement. [Jan. 

vegetable body is constantly swelling, and each access of dyspnoea will be 
more severe than the last. 

21 til. Hdematocele. — Dr. J. M. Warren exhibited the specimenj showing 
the tunica vaginalis, thickened to nearly a quarter of an inch, and distended 
to hold a pint ; its inner surface being lined with coagulated lymph. The 
case was peculiar and instructive. The patient had carried the tumour nine- 
teen years ; its origin being unknown. When he presented himself, it was 
of the size of a cocoanut, firm, without fluctuation, and presenting an in- 
flamed spot upon its anterior aspect. The tumour was considered as one of 
the testicle, and its removal advised and practiced. The sac was not punc- 
tured during the operation. On being laid open afterwards, it gave issue to 
a dirty-coloured fluid. The testicle, after the removal, was found flattened 
and wasted on the posterior face of the sac. The recovery was perfect in two 
weeks ; and, although there was a mistake in the diagnosis, the operation per- 
formed was the best for the patient, as the process of granulation in so thick- 
ened a sac must necessarily have been very tardy, and the testicle was no 
longer of any efficiency. A circumstance which added to the difficulty of the 
diagnosis was, that the other testicle had commenced enlarging during the 
past year, was double its natural size, and much flattened, and evidently had 
no water external to it. Both the patient and his physician insisted that the 
disease of the other testicle commenced in the same way, and the latter 
stated that he had often examined it with the view of detecting fluid in the 
tunica vaginalis, but never could discover any. 

Dr. S. Parkman alluded to two similar cases of greatly thickened sac, in 
cases of haematocele occurring in his practice at the hospital. In one, a young 
man, the disease had existed four years, originating without injury, and pre- 
senting all the appearance of hydrocele, save the transparency. The tumour 
was tapped, and several ounces of a bloody fluid were discharged. The thick- 
ened sac being then readily perceived, was laid freely open, and a portion 
excised ; its inner surface was lined with grayish matter, evidently the result 
of the coagulum of the efi'used blood. The cavity granulated from the bot- 
tom, and the patient did well. The other case, a man seventy-five years of 
age, presented himself with the same symptoms of hydrocele, without the 
transparency, existing for nine months without known cause. At his urgent 
request, the tumour was punctured, and about eight ounces of black fluid 
blood followed the withdrawal of the trochar. The man died from gangren- 
ous inflammation of the scrotum, and the sac presented similar appearances to 
those in Dr. W.'s specimen. 

Oct. StJi. Hare-lip — Nursing during the Process of Union. — Dr. J. M. 
Warren had lately, in a child one month old, permitted nursing during the 
process of union. Three sutures were employed, and the union was perfect ; 
and he was surprised to see, contrary to the usually received opinion^ that 
there was no strain on the lip during the act of nursing. 



1850.] Parkman, Extracts from Soc. for Med. Improvement. 75 

Animal Poison. Dr. Fisher. — R. S. W.^ aged forty, residing in Ded- 
liam, on the 5th day of September, dressed a sore on the leg of a horse, 
which had existed a few days, and caused the limb to swell enormously. At 
the time of dressing the sore, the patient did not know that he had any abra- 
sion of the skin of his hand or fingers. On the second day after dressing 
the sore, he perceived a small pimple of a lengthened form on the dorsum of 
the little finger of the right hand, situated midway between the second and 
third joints. His attention was directed to the pimple by an itching sensa- 
tion, which caused him to rub it often. The pimple soon began to increase 
in size and the finger to swell, so that, at the end of two weeks, the finger had 
enlarged to three times its usual dimensions, becoming very painful and red, 
and sore as a common boil. At this period, he applied poultices to the finger, 
without, however, relieving the pain or diminishing the swelling. During 
the third week, red lines were observed by the attending physician passing up 
the inner surface of the right arm, and the arm began to swell ; and in a 
short time the whole arm from hand to axilla attained to double its common 
size. The glands in the axilla became tender, painful, and sore to the touch. 
At this' time, the original sore on the finger had assumed a purplish colour ; 
and by the middle of the third week, its surface opened, and a little thin, 
dark liquid came from it. The glands of the right groin now became painful, 
swollen, and tender, and the right lower extremity became swollen, and the 
inner side of the whole limb, especially along the tract of the large blood- 
vessels, became sore. At about the same period, the patient experienced a 
general soreness in the abdomen. This cavity became distended and tender, 
so that the weight of the hand caused much pain. The glands of the right 
side of the neck were also aiFected, and became enlarged, painful, and sore. 
In one or two days after the whole of the right half of the body had become 
thus afiected, the left half became involved. The glands of the left side of 
the neck, of the left axilla and groin, and the inside of the left leg became 
afi"ected, but not to the degree that was experienced in th'e same bodies and 
regions of the right side. The left arm and leg were not much swollen, but 
were as painful as were the right arm and leg. The sore on the finger was 
opened three weeks after the first appearance of the pimple, and discharged 
matter freely until Oct. 12th. The swelling, soreness of the limbs and glands, 
gradually subsided with the progress of the discharge from the sore ; so that, 
on the. 16th of October — the day of my second and last visit to the patient — 
the affected members and parts had assumed nearly their natural size and 
sensations. 

The general symptoms were chills and fever -, numbness in all parts of the 
body; a kind of catalepsy of the limbs; occasional feeling of fainting; 
nausea without vomiting ; dull pains in head and back ; quickness of pulse ; 
palpitations of the heart ; loss of appetite ; oppression in epigastrium after 
meals ; constipation of bowels ; difficult micturition ; great debility ; watch- 
fulness. 



76 Parkman, Extracts from Soc. for Med. Improvement. [Jan. 

The treatment was poultices to sore ; brandy and quinine in frequent and 
large portions. As has already been stated^ the patient^ on October 16th, 
forty-one days from the time of the infection, had recovered, or nearly so, the 
usual size of his limbs, and their usual sensations. He was still much debili- 
tated, and complained of some degree of numbness in the right arm and little 
finger. The wound on the finger had healed ; but had left a rather broad- 
lined scar. The finger was larger than natural, hard, and the skin covering 
its upper surface thin and glossy. The scar was one inch in length. 

The horse, from whom the patient received the infection, had a small wound 
on his limb ; and, after a few hours of rapid travelling, the limb began to 
swell and became very large, and the sore to discharge matter. The animal 
was sick two weeks, and recovered. 

The owner of the horse suffered severely from a sore situated on the end 
of one of his thumbs, which he now thinks was caused by dressing the wound 
on his horse. The skin on the thumb was not broken at the time. The 
thumb swelled ; matter formed in it, and was discharged by an operation. 
No constitutional symptoms followed this infection. 

Aug. 17. Asiatic Cholera. — Hydropathic Treatment. — Dr. Stedman read 
the following paper : — 

I deem it my duty to submit to the notice of this society the following 
cases, in which the employment of an old remedy in a new disease was 
adopted. I refer to the extensive application of cold water to the body of 
patients afflicted with Asiatic cholera. I proff'er these notices, in the hope that 
others of our profession may be induced to make trial of the same remedy, 
and meet with the same beneficial results. 

On Saturday, Aug. 18th, J. M., a man who had just recovered from in- 
sanity, and was waiting at the Boston Lunatic Hospital for an opportunity to 
proceed to his home in Nova Scotia, was seized with cholera in the severest 
form. In three hours from the appearance of decided signs of the disease, 
he was in a state of profound collapse, as was manifest from the feet and 
hands becoming cold, blue, and shrivelled ; the eyes sunk in their sockets and 
the eyelids of a dark livid colour; the eyes themselves being injected with 
blood. Lips dark blue ; voice reduced to a whisper ; respiration laborious ; 
tongue and breath cold ; pulse imperceptible everywhere, except a faint flutter- 
ing over the cardiac region; frequent and copious oral and anal ricewater-like 
evacuations ; incessant cramps in legs and arms. 

Immediate dissolution was threatening. From the beginning no relief had 
followed the use of remedies, and I was about retiring to rest, after a very 
fatiguing day's work, feeling assured that death must terminate the patient's 
suff'erings in the course of a few hours, when my eyes rested on the uncut 
leaves of the London Lancet received by the last steamer. On glancing over 
the table of contents, I read this caption, " Treatment of Cholera by external 
cold and moisture.'^ Turning to the page indicated, I there found a communi- 



1850.] Parkman, Extracts from Soc. fm- Med. Improvement. 77 

cation from two surgeons (who gave their names and residence at the close 
of their letter); stating the success they had met with in the treatment of 
cholera by the application of the wet sheet and blankets ; and this in the last 
stage of the disease. They had by these means succeeded in restoring heat 
to the surface in twenty cases. 

Having read this paper, I was reanimated to further exertion in behalf of 
the apparently dying man, and immediately directed the application of the 
wet sheet and the blankets to be made. In half an hour, the patient was 
relieved of all cramp; vomiting and purging ceased; his respiration became 
gentle, and he dozed quietly for ten minutes. In forty-five minutes from the 
time when he was first inclosed in the sheet and blankets, he was taken out 
entirely relieved. The pulse at the wrist returned; respiration was easy; 
warmth was restored to the whole surface; while, at the same time, the blue 
colour of the skin gave way to its natural redness. In short, healthful reaction 
had taken place. 

In two hours and a half after this, the patient grew worse; his cramp, vomit- 
ing, and purging returned ; and the pulse again became imperceptible. He 
was agaiD subjected, for forty minutes, to the same treatment as before, with 
precisely similar good results. 

Again, after an interval of eighteen hours, relapse followed; the same pro- 
cess of treatment was instituted, and the same relief resulted — since which 
time, the patient has been rapidly convalescing, and is now, with the exception 
of some debility, quite well. 

The next case treated by the application of the moist sheet and the blan- 
kets was that of Susan M'D., a common drunkard, who was sent to the 
House of Correction, on the 20th of August, and to the Prison Hospital on the 
next day; when, at 11 o'clock P.M., she was seized with vomiting and purg- 
ing of ricewater-like fluids in large quantities, with cramps in both extremi- 
ties, &c. &c. 

At 1 o'clock A. M. of the 22d, I found her in a state of collapse, nearly as 
deep as in the case above detailed. The same treatment was adopted in this 
as in the last case ; in half an hour from the commencement of which, all the 
bad symptoms ceased ; the pulse returned, with general warmth and natural 
colour of the surface. She was soon released from her envelope, placed in 
bed, and covered with the customary quantity of clothing. In two hours 
after, she again fell into a state of collapse ; was again enveloped in the wet 
sheet, &c. ; and became completely relieved, as before. 

At 8 o'clock A.M., collapse returned; the same treatment was pursued as 
before, and was attended by the same relief. At 2 o'clock P. M., she was 
attacked with delirium tremens, and was soon after submitted to the apphca- 
tion of the same remedial means. The delirium subsided gradually, and dis- 
appeared in the course of the following night. Twice after this, bad choleraic 
symptoms appearing, she underwent the water treatment, as before. On the 
No. XXXVIL— January, 1850. 6 



78 Neill on Occipital and Maxillary Bones of the Negro. [Jan. 

24th, for the first time since the attack, the urinary evacuations occurred, and 
then but scantily. 

On the 25th, patient had a copious bilious discharge from»the bowels, and 
passed urine in abundance. From this period, convalescence has progressed 
rapidly without impediment. 

I will not encroach further on your time than to say that all the cases of 
cholera which have occurred in the city institutions at South Boston, since 
August 18 (eight in all), have been treated by the same method as mentioned 
above, and, with one exception, with the same happy result. The patient ex- 
cepted, who died at the House of Correction, was a confirmed sot, and seemed, 
from the first, to have but little stamina of constitution left, with which he 
might combat any disease. 

Reaction indeed took place each time that he was incased in the wet sheet; 
but the intervals of relief became more and more short, as his end approached. 

It is proper further to remark that, in none of these cases, were the patients 
subjected to this mode of treatment till the stage of collapse had become 
fully determined; and also, that no adjunctive remedies were employed during 
this stage of the disease. 

To this paper. Dr. S. appends the following note : — 

The above account was written immediately on the termination of the last 
case enumerated. Since that time, though the same mode of treatment was 
employed in many instances, and in all warmth was restored to the whole 
skin, and perfect reaction seemed to have followed in each case, yet the patient 
seldom rallied, but for a short period, and soon fell ofi", and sunk irrevocably. 

Such being my experience, after the most careful management, and so 
thorough the trial of this mode, and, at length, that of the administration of 
other remedies in conjunction with it, I became satisfied that no special course 
of treatment, however successful in one locality or during one epidemic out- 
break of cholera, would serve as a uniform standard, according to which we 
might be governed in our general treatment of this mysterious disease. 



Art. V. — Observation?, on the Occipital and Superior Maxillary Bones of the 
African Cranium. By John Neill, M. D., Demonstrator of Anatomy in 
the University of Pennsylvania. [With six woodcuts.] 

Having noticed, within the last few years, a peculiar formation of the 
condyloid processes of the occiput, which is not ordinarily described, I have 
been led to make some investigations with reference to this point of special 
anatomy. 

Generally, these processes have been described as oblong and converging 



1850.] Neill on Occipital and Maxillary Bones of the Ntgro. 



79 



eminences, on each side of the anterior semi-circumference of the foramen 
magnum occipitis, having smooth and convex surfaces for articulating with 
the atlas, the internal margins of which are deeper than the external, and 
with a roughness on the inside and a depression on the outside, for the attach- 
ment of ligaments. 

But, in many instances, this description will be found deficient, with regard 
to a striking peculiarity, which is exhibited in several varieties of form ; but 
they are all modifications of each other, and produced by the same cause. 

In some instances, it will be found that the articulating surface of the con- 
dyloid, instead of being oval, presents the outline of the figure of 8. In 
others, that it is divided by a transverse ridge or groove into two distinct arti- 
cular surfaces, which are often in different planes. 

The accompanying woodcuts 
(Figs. 1 and 2) exhibit these ^ig- 1- 

varieties much more distinctly 
and satisfactorily than any ver- 
bal description. 

After having been satisfied 
that this peculiarity was of fre- 
quent occurrence, it became 
important to inquire whether it 
was common to any particular 
class of heads, or whether it 
was in any degree characteristic 
of any of the great divisions of 
the human race. 

The crania in my own pos- 
session which exhibited this 
process most strikingly, were of 
the African variety. Still, no 
conclusion could be ventured 
upon, without an examination, 
upon the largest scale, of speci- 
mens known to be authentic. 
At the Academy of Natural 
Sciences, in this city, I found 
full opportunity for this inves- 
tigation. This Institution con- 
tains the best and most exten- 
sive collection of crania, probably, in the world. There arc found nearly 
nine hundred skulls, deposited by Dr. Samuel Gr. Mor!:on, whose contributions 
to the science of craniology have constituted him an authority upon this sub- 
ject, and to whom I am indebted for much valuable assistance, in the selec- 
tion and examination of the specimens, and in the preparation of the following 
table : — 




FiR 2. 




80 Neill on Occipital and Maxillary Bones of the Negro. [Jan. 

TABLE. 





Nation. 




Number of Heads. 


Exhibit the Mark 




''European 
Anglo-American 
Armenian 


\ 


47 
6 






Caucasian -^ 


Arab 

Fellah 

Graeco-Egyptian 




3 
12 

27 








^ Pure Egyptian 




30- 


-125 


4 


Mongolian 


; Chinese 
Malays 
' Peruvians 




6 
18 






Aboriginal Americans 


Mexicans and 
Barbarous tribes 


\ 


105 




3 


Negro 


; African 

\ New Hollanders 




81 




30 




10 







No heads are here included that are of doubtful history, although many such 
specimens of my own possess this feature in a striking degree. The originals 
of the above drawings are not introduced into this enumeration^ because of 
their want of authenticity. 

From this table, it appears that this feature occurs often in the African, 
and but rarely in any other race. Many of these pure African heads were 
obtained directly from the coast of Cuba. They belonged to what are termed 
the "unbaptized'^ blacks, who died in the slave-yards, or barracoons; of 
course, they had never been upon a plantation. Others were obtained di- 
rectly from the coast of Africa. 

Statistical results, still more striking, could be produced, if all the very old 
heads were excluded from the examination. In these, the condyloid process is 
often rendered flat and smooth, by the effect of the constant weight and motion 
of the head; and still greater would have been the proportion, if the heads of 
growing children had been introduced. 

But, to trace the analogies of this formation, and to observe in the human 
species the illustration of a law which has been developed by Agassiz, and 
proposed by him as the basis of a zoological classification, is still more inte- 
resting than its discovery as a fact, its examination as a point of special ana- 
tomy, or its establishment as a characteristic of any variety of the human 
species. 

This great law, or principle, is thus stated, ^Hhat, in the different formations 
through which animals pass, from the first formation in the embryo up to the 
full-grown condition, may be found a natural scale, by which to measure and 
estimate the position to ascribe to any animals.'^ For instance, in the meta- 
morphoses of the frog, we have the key to the natural classification of the 
Batrachians. At first, there is an animal without tail, gills, or feet. They 
that permanently retain this condition are lowest in the class, as the Cascilia; 
next, the animal assumes gills, and two rudimentary legs, corresponding to 
the siren, which is a step higher; then two more legs and a tail appear, cha- 
racteristic of the Proteus; and^ finally, the tail is shortened — the perfect 



1850.] Neill on Omvpital and Maxillary Bones of the Negro. 



81 



Fiff. 



animal is formed.* Thus we see that the changes which take place during 
the development of the embryo to the completion of the perfect animal, 
shadow forth the natural classification of the animals belonging to that class. 

May we not apply this principle to the classification of the human species ? 

Let us examine the condition and changes of the condyloid process of the 
foetus, and then compare it with the same process in the lower orders of ani- 
mals. 

In the foetal human head, the occiput 
consists of four pieces, as represented 
in the figure. The first piece, or basi- 
occipital bone of Owen,-f- is separated 
from the two lateral portions by a fissure 
running through condyles. This piece 
remains permanently separated in the 
cold-blooded vertebrata;| and, in the 
African cranium, we constantly see the 
remains of this fissure permanently re- 
tained in the adult, in the form of a ridge 
or groove separating the condyloid pro- 
cesses into two distinct articular surfaces 
adult African head, the basi-occipital bone frequently retained. Here we see 
the African assuming his proper position among human beings by a natural 
law based upon the development of the bones of the cranium. It will be 
seen, from the drawings, that the basi-occipital of the adult African forms a 
much larger proportion of the condyloid process than it does in the foetal head. 
This is readily accounted for, when it is recollected that this portion of the 
occiput grows much more rapidly than the others, in some of the inferior 
animals. 

When this feature of the occiput first came under my observation, I was 
not aware of its having been previously remarked or described. There is 
no notice of it in the works of any anatomist, ancient or modern, which it 
was convenient for me to examine,§ with the exception of IMunro, who has 




or, in other words, we have, in the 



* Lectures on Comparative Embryology, before the Lowell Institute. By Louis Agassiz. 
Reported by Dr. Stone, Boston, 1848. 

t "For '■ basilaire^'' which Cuvier exclusively applies to the 'pars basilaris' of the occi- 
put, and which Geoffrey as exclusively applies (in birds) to the ' pars basilaris' of the 
sphenoid,! have substituted the term 'basi-occipital' (.basioccipitale, Lat.),a term which, 
as it is more descriptive of the bOne in question," &c. &c. — On the Jrchefype or Homologies 
of the Vertebrate Skeleton. Richard Owek, F.R.S. London, 1847, p. 9. 

J Wagner's Anatomy of the Vertebrate Animals. Translated by Alfred Tulk, N. Y., 
1845, p. 5. 

§ I have examined the works of Winslow, Morgagni, Veslingius, Vesalius, Ruysch, 
Bartholin, Bellini, Bonetus, Riolanus, Mangetus, Cheselden, Sandifort, Vicq. d'Azyr, Bruno, 
Craigie, Caldani, Cowper, Albinus, Bertin, Meckel, Cloquet, Lizars, Heister, Cruveilhier, 
Cuvier, Sappey, Bell, Sabatier, Portal, Bichat, Boyer, Wistar, Horner, Morton, Harrison, 
Quain and Sharpey, Wilson, Von Baer, and the Encyc,"of Anat. and Physiol. 



82 



Neill on Occijpital and Maxillary Bones of the Negro. 



[Jan., 



the following: ^^In some subjects, eacli of these plain, smooth surfaces seems 
to be divided hy a small rising in its middle, and the lower edge of each con- 
dyle, next the great foramen, is discontinued about the middle, by an inter- 
vening notch; whence some allege* that each of the apophyses is made up of 
two protuberances." — Munro's System of Anat. and Physiology, Edin. 1795, 
p. 83, vol. i. 

Otto also says, ^^The articular processes jut out too much, and are too deeply 
articulated, or are too flat, and at the same time sunk in, oblique, unequal, 
divided into two surfaces, &c. &c." — Comp. Human and Compar. Pathol. 
Anat. By Ad. Wilhelm Otto. Translated by John F. South : London, 
1831, page 171. 

This testimony of course destroys all claim to priority in the discovery of 
the fact, but, nevertheless, adds great weight to the truthfulness of the ob- 
servation. 

The Superior Maxillary hone also presents, in the African head, a distin- 
guishing mark, whefreby it can readily be recognized, and which also carries 
out the same views of the classification of the human species, when examined 
in its foetal condition, and compared with its analogue in the inferior animals. 

The portion referred to is the inferior edge of the anterior nares. In the 
Caucasian head, there is a sharp edge or crest, continuous with the anterior 
edge of the nasal process, and reaching to the anterior nasal spine (Fig. 4). 

Fig. 4. Fig. 5. 





In the African head, this crest is wanting, the surface is flat, and the orifice 
of the nose resembles that of the monkey, and Other inferior mammalia (Fig. 
5). This diff"erence is so striking and uniform, that any one can recognize 
the distinction at once. The fact is so well known to anatomists in this city, 



* Processus duo majusculi ad magni foraminis medullse latus, oris interiora spectantes, 
adstant; quibus duo iriinores et plani paulo retrorsum versus, juguntur; qui omnes lubrica 
cartilagines tecti ad finibus primse vertebrae excepiuntur et articulationi capitis inserviunt. 
Dieraerbroeckj lib. 9, cap. 6. 



1850.] Ainsworth's Case of Ligature of the Subclavian Artery, 



83 



that I have not thought it necessary to add any 
tables of comparison at this time upon the point; 
although the merit of the discovery is somewhat 
doubtful. 

Now, when the foetal superior maxillary bone 
is examined (Fig. 6), it will be found that this 
ridge or crest is also there deficient, and the 
surface is flat. 

Here we again see that the adult African head 
permanently retains a form characteristic of the 
foetal head, and that this form belongs to many 
inferior animals. 

At some future period, I hope to be able to 
establish this truth in other bones of the cranium. 




Art. VI. — Notice of the Anator)iical Phenomena in a Case of Liaaiure of 
the Subclavian Arteri/, four years subsequent to the Operation. By F. S. 
AiNSWORTH, M. D., Demonstrator of Anatomy, Mass. Med. College. 
(Communicated to the Boston Society for Medical Improvement.) 

J. A., a man 35 years of age, of intemperate habits, was admitted to the 
Massachusetts General Hospital, Dec. 2od, 1843, for an injury of the left 
shoulder. According to the account given by the patient, the shoulder had 
been dislocated by a fall on the curbstone. Medical aid was obtained ; and 
the operator had attempted the reduction of the joint, by placing the heel, 
without removing the boot, in the axilla, and making extension in the usual 
manner. 

At the time of his admission, the shoulder and adjacent parts were so much 
swollen, and so painful, that it was impossible to determine whether the head 
of the humerus was in place. A large ecchymosed spot was remarked in the 
axilla. 

Six days after admission, it was ascertained that the head of the humerus 
was in place, and the movements of the arm were restored. 

January 3d, eleven days after the accident, the shoulder again became 
much swollen, discoloured, and painful. Sensation in the hand was diminished ; 
tlie temperature was natural. There was little constitutional irritation ) the 
pulse in the right arm counted 88 ; but no pulsation could be felt in any part 
of the left. A hard flat tumour was felt in left axilla. 

From that time till Jan. 28th, the tumour in left axilla continued to en- 
large, until it came to fill the entire space of the arm-pit. At the same time, 
the skin over it became discoloured. There was distinct fluctuation, and a 
tendency to pointing. Notwithstanding all these appearances of abscess, and 
the fact that a feeble pulsation was again perceptible in the radial artery, it 
was judged best not to open the tumour with the knife. At that time, the 
tumour opened spontaneously, and a thin sanguineous fluid was discharged. 
There continued to be an oozing of blood, in small quantities, and without 



84 Am^YfOx\)oLB Case of Ligature of the Subclavian Artery. [Jan 

jet^ until Feb. 7th, when a copious hemorrhage took place, preceded by intense 
throbbing pain, and followed by extreme prostration and syncope. The day 
following, one month and fifteen days after the accident, a ligature was 
applied by Dr. J. C. Warren to the left subclavian artery, above the clavicle, 
and at the external border of the anterior scalenus muscle. 

The operation was rendered exceedingly difficult, by the infiltration of all 
the tissues traversed by the incision; by the alteration in the anatomical rela- 
tion of the different parts; and from the great swelling about the shoulder- 
joint, extending over the whole left side of the neck. The operation was 
performed in the usual manner ; two small arteries were divided, and secured 
by ligature. In passing the ligature around the subclavian artery, a whis- 
tling sound was heard, as of air entering the cavity of the pleura. Pressure 
being instantly made upon the left chest, the wound was closed as soon as 
possible, and the patient removed from the operating room. No incon- 
venience was experienced from the supposed opening into the pleura, as might 
have been expected from the nature of the operation and the previous loss of 
blood, the patient being reduced to a most critical state for some hours. He 
rallied well, however; no loss of vitality was apparent in the left arm; some 
discoloration was perceptible about the elbow, which disappeared in a few 
days. 

The patient continued to improve, and, the thirteenth day after the opera- 
tion, the ligature came away, without immediate hemorrhage. Ten days 
afterwards, and twenty-three days after the operation, while lying still in bed, 
there was a sudden gush of blood from the external part of the wound in the 
neck, of an arterial character, and to the amount of a pint and a half The 
bleeding was controlled by the introduction of a sponge. Ten days afterwards, 
another hemorrhage of similar character was experienced, which was again 
stopped by the sponge tampon. From this time the wound over the clavicle 
occasioned little trouble. The swelling in the axilla continued to discharge a 
purulent matter, and had been exceedingly painful. On the 23d of March, 
three months after the injury was sustained, a coagulum came away from the 
axilla the size of a goose egg, followed by a copious discharge of fetid pus ; 
this was succeeded by diminution of pain in the tumour in the axilla. 

From this time, till his discharge from the hospital, Sept. 29th, 1845, the 
patient gradually improved; the wound in the neck had healed; the abscess 
in the axilla continued to discharge pus through several fistulous openings. 
The shoulder-joint was immovable; pulsation, feeling, and natural heat were 
restored to the arm, and the patient was able to walk about and perform 
light work. Some months afterwards, he was admitted to the Hospital of 
the House of Industry, where he remained discharging the duties of ward 
tender until his death. During his last illness (from dysentery), at the sug- 
gestion of Dr. Charles H. Stedman, the resident physician, he gave up his 
body for dissection. After his death, it was removed to the Medical College. 

The arteries of the upper extremities were filled from the abdominal aorta, 
the injection running freely into all the vessels of the left arm and hand. In 
the neck, the arteries, veins, and brachial plexus of nerves, for the space of 
three inches above the clavicle, were imbedded in a dense fibro-cartilaginous 
substance. The subclavian artery was completely obliterated at the point 
where it comes out from the anterior scalenus muscles, and reduced to a mere 
fibrous-looking cord. It regained nearly its usual size at the distance of three- 
quarters of an inch from that place, and continued, throughout its whole 
course, of normal dimension and distribution. The collateral circulation was 
maintained by the intercostal branches of the internal mammary, through the 



1850.] Ainsworth^s Case of Ligature of the Subclavian Artery. 85 

thoracic branches of the thoracico-acromialis, and by a large inosculation be- 
tween the supra-scapular artery and a terminal branch of the subscapular. 
A communication was also traced between some small muscular branches of 
the transverse cervical and the thoracico-acromialis. A slight, but common 
irregularity was observed in the transverse artery of the neck, which came off 
from the thyroid axis in a common trunk with the posterior scapular, forming 
a large arterial trunk, passing across the neck just above and parallel to the 
clavicle, corresponding in the first parts of its course with the subclavian 
artery. It is easy to conceive how much such an irregularity might increase 
the difficulties of the operation of ligature of the subclavian, either from the 
danger of wounding it, or of mistaking it for the larger trunk, from which, 
in this case, it could hardly have been distinguished, except by its superficial 
position with relation to the scalenus muscle, and the tubercle of the first rib. 
The same irregularity occurred in a patient of Dr. J. M. Warren, where 
ligature of the subclavian was performed for aneurism of the axillary artery. 
In this case, the transverse cervical artery was so superficial as to be distinctly 
felt immediately under the skin. 

Anomalies in the origin of the subclavian artery, and particularly of the 
thyroid axis, are sufficiently common ; most of them have little importance 
in the operation which has been described. In a subject dissected at the 
Massachusetts Medical College, an anomaly was observed which the writer 
has never seen described, and which would materially interfere with the suc- 
cess of this operation. 

In this case, the thyroid axis with its branches was given off from the 
right subclavian artery, at the distance of an inch and a half from the ex- 
ternal border of the anterior scalenus muscle; and the internal mammary 
came off under the clavicle, and, passing over the first rib, penetrated the inter- 
costal muscles, to be distributed as usual. 

The vertebral^ the profunda cervicis, and a small muscular branch, were 
given off under the scalenus muscle. It is easy to see that, were a ligature 
to be applied to the subclavian artery at the usual place, in such a case, all 
the arteries which kept up the circulation, in the case described, would have 
been stopped by the ligature. A reference to the statistics of the operation of 
ligature of the subclavian artery shows a large number of fatal cases from 
hemorrhage, coming on, as in Dr. Warren's case, after the lapse of two or three 
weeks from the operation. In the examination of the case under considera- 
tion, the idea suggests itself, that this untoward circumstance may be due to 
small muscular branches, the cardiac extremities of which were tied during 
the operation. There must have been a reflex current in that part of the 
subclavian artery lying between the origin of the subscapular artery in the 
axilla and the point where the artery became obliterated, near the scalenus 
muscle. All the small arteries arising from this portion of the subclavian 
would of course be filled by a similar current, running toward the heart. 
Some of these small anastomoses were found, and in the operation two 
branches are said to have been divided. If this hypothesis concerning the 
cause of these frequent bleedings in cases of ligature of large arteries be true^ 
it is evidently of importance that, in all cases where a collateral circulation 
will be produced, both extremities of all arteries should be secured. 



86 Detmold, Abscess in the Substance of the Brain. [Jan. 



Art. VII. — Abscess in the Substance of the Brain; the Lateral Ventricles 
opened by an Operation. By Wm. Detmold^ M. D., of New York. 

Francis Miller, setat. 40, of a rather phlegmatic temperament, a well- 
developed head, and good constitution, a native of Grermany, was, on the morn- 
ing of the 14th of July, 1849, at work in a machine shop, when a derrick 
broke down, and a piece of the machinery struck him with great force on the 
left side of the os frontis. The force of the blow may be estimated from the 
fact that the same piece which struck Miller killed two men, besides severely 
injuring some others, who were all at work underneath. 

Miller was carried home insensible, and was first seen by two medical men, 
whose names I have not ascertained, and who ordered cold applications. My 
friend Dr. Miller was called in in the evening, and found the patient fully re- 
covered from his insensibility, the wound and the parts around much swollen, 
the conjunctiva of the left eye much congested. There being no very urgent 
symptoms, and the swelling precluding a minute examination of the wound, 
Dr. Miller ordered the cold fomentations to be continued ] bled the patient 
freely, and prescribed a solution of the nitrate of potash, and a strictly antiphlo- 
gistic regimen. Under this treatment, the patient got along very well; the 
wound yielded a healthy pus, and the swelling gradually went down. About 
the third week after the injury, a bloody diarrhoea came on, the patient having 
had: an attack of dysentery before the accident occurred. This relapse yielded 
readily to proper treatment. 

On the 8th of August, Dr. Miller discovered a loose piece of bone in the 
wound, which he removed, and which measured in its longest diameter, which 
was the transverse one, a full inch, and in its short diameter one-third of an 
inch ; the piece consisted of the entire thickness of the frontal bone, which 
was remarkably thin. After the removal of the first piece. Dr. Miller, upon 
careful examination, found another piece of bone loose, but was unable to re- 
move it without dilating the wound. Fearing that this piece of bone, if left 
in its position, might lead to trouble, he requested me to see the patient the 
following day with him. 

On the 9th of August, I saw the patient for the first time; I found a small 
suppurating wound on the left side of the os frontis, about three inches above 
the supra-orbitar margin, and about midway between the linea semicircularis 
and the median line of the os frontis. The patient was lying in bed, with 
slight symptoms of pressure on the brain. He was in a state of apathy rather 
than of stupor ; he could easily be roused, and answered all questions 
promptly; his pulse natural, about 75 per minute, without any farther morbid 
symptoms. I found the loose piece of bone, which Dr. Miller had described 
to me, at the upper edge of the wound, in which the denuded dura mater 



1850.] Detmold, Abscess in the Suhstance of the Brain. 87 

could be felt pulsating. I dilated the wound upwards, and discovered that 
the piece of bone in question was only a few lines in circumference, but that 
the fracture extended farther in the inner table of the bone than the outer, 
which was perfectly firm. With a strong forceps, and making horizontal 
traction, so as to avoid pressure and perhaps laceration of the dura mater by 
the inner edge of the bone, I succeeded with a slight effort in disengaging 
the piece, which measured nearly a square inch of the tabula interna. During 
the enlarging of the external wound, the patient exhibited great sensitiveness, 
and immediately after the removal of the piece of bone, he brightened up, 
and professed himself decidedly relieved. Upon further examination with 
the finger, I did not discover any more loose bone ; and, the patient declaring 
himself so decidedly better, and very averse to farther interference, which 
indeed at the time did not appear to be called for, cold applications and 
strictly antiphlogistic regimen were ordered, and I left the patient again under 
charge of my friend Dr. Miller, with the remark that I feared more trouble. 

In a few days, fresh and healthy granulations sprang up in the wound, 
which in about a fortnight was entirely closed, and the patient went about 
again apparently well, and without complaining of anything. 

On the morning of the 13th of September, nearly nine weeks after the acci- 
dent, and about five weeks after the removal of the above-mentioned pieces of 
bone. Dr. Miller called on me again, and stated that the patient had, on the 
day previous, complained of headache, and had become drowsy. He had 
seen the patient just before he called on me, about nine o'clock in the morning, 
and had found him in a stupor, from which, however, he could be roused, and, 
when requested to show his tongue, would readily put it out : pulse 60 in the 
minute. As I had to operate for stone in the bladder at one o'clock, P. M., I 
invited Dr. Miller to be present, immediately after which, I promised to see 
his patient. I invited all the gentlemen who witnessed the operation for 
stone, also to see this case. Prof. S. H. Dickson, Dr. Carnochan, Dr. Miller, 
Dr. Schirmer, Dr. Wilhelm, Dr. Michaelis, Dr. Meyer, and several others 
whose names I do not at present recollect, besides some ten or twelve medical 
students, accompanied me to witness the following operation. It was about 
two o'clock before all the above gentlemen reached the house, which was at 
a distant part of the city. 

We found things much changed for the worse, since Dr. Miller had seen 
the patient in the morning. The patient was now in a profound stupor, 
from which nothing could rouse him, lying motionless, but neither paralyzed 
nor convulsed; breathing stertorous; pulse 40 in a minute, and occasionally 
intermitting ; pupils immovable. In the place of the original wound, we 
found a deep adhering cicatrix, which communicated to the finger distinctly 
the pulsation of the brain. 

There was evidently no time to be lost; but we had first to overcome the 
most obstinate resistance on the part of the family and friends of the patient. 



88 Detmold; Abscess in the Suhstance of the Brain. [Jan. 

Considering him hopeless and dying, they were unwilling to have his last 
moments disturbed. As I afterwards learned, nothing but the large number 
of doctors present induced them to yield. We laboured under the disadvan- 
tage of not having things as well prepared as we could have wished, for, 
fearing the opposition might gain strength, we lost but little time in prepara- 
tions. Thus, we had a decidedly bad and insufficient light, and I do not know 
whether I should have been able to succeed, had I not been ingeniously aided 
by Professor Dickson, who, by means of a looking-glass, threw a full reflected 
light upon the field of operation. 

The time which had elapsed since the accident, in addition to the fact that 
the patient had been about until lately, although, according to his wife's 
account, he had not been so lively since the accident, left, under the present 
symptoms, very little doubt as to the nature of the case. I anticipated an 
abscess, and even thought that I felt fluctuations under the adhering scar. I 
stated this before commencing the operation, but admitted that I was not 
positive, being aware that the tense dura mater, with the brain underneath, 
might deceive me. 

I commenced by surrounding the adhering cicatrix with an incision, so as 
to leave that at first untouched, and then made several incisions in different 
directions, in search for fractured bone. In the upward direction, where I 
had on the former occasion removed the piece of bone, I found the skull 
firm; but the fracture extended inward towards the median line, downward 
towards the supra-orbitar ridge, and outward towards the semicircular ridge; 
so that the original wound, and the first deficiency of bone, formed the upper 
and middle point of the entire wound. By carefully carrying on the in- 
cisions, as far as I could readily with my finger separate the pericranium 
from the bone, I successively removed three large pieces of bone, which, in- 
cluding some small splinters, and the two pieces removed before, made an 
opening into the left half of the os frontis which measured about five square 
inches. The opening extended to within half an inch of the supra-orbitar 
margin ; and the outer piece had formed part of the linea semicircularis. All 
the pieces showed strong marks of absorption, the edges being rounded off", 
and the surface uneven and porous. Professor Dickson expressed his fear 
that the supra-orbitar margin might be fractured, and the injury extend to 
the base of the skull — a fear which the final result proved to be but too well 
founded. But, as all the edges which surrounded this now large defect of 
bone were apparently firm and immovable, and as the pericranium everywhere 
strongly adhered to the bone, I concluded that I had removed all the frag- 
ments, although the condition of the patient was not in the slightest degree 
improved. By the lateral incision, I had divided the temporal artery, and 
allowed it to bleed freely, but it made no impression on the patient. It was 
remarkable, and I looked upon the fact as a favourable sign, that, notwithstand- 
ing his profound stupor and general insensibility, the patient exhibited unmis- 



1850.] Detmold^ Abscess in the Substance of the Brain. 89 

takable signs of intense pain at every incision through the integuments. 
After having cleared the wound of bloody the dura mater appeared, throughout 
the whole extent of the wound, in a natural condition, with the exception of the 
adhering cicatrix, which had been left as a small island in the upper part of the 
wound. Finding that the removal of the fragments of bone had not changed 
the condition of the patient, and also finding all the bony limits of the defect 
firm and without any depression, I proceeded to dissect off the adhering cicatrix, 
removing with it the dura mater to the same extent, as the cicatrix was adhering 
to it, and brought the brain itself into view, covered with the pia mater, which 
appeared thickened. I then introduced a probe under the dura mater, and 
passed it around the whole opening between the dura and pia mater, to ascertain 
whether anything morbid could be found there ) but the probe passed freely 
round, being plainly visible through the transparent membrane. I now felt 
again, with great anxiety, for the fluctuation which I thought I had detected 
before commencing the operation; but the removal of such a large portion of 
bone, and the opening of the dura mater itself, had taken away all tension, 
and I did not discover any fluctuation. Confident, however, that an abscess in 
some part of the brain was the cause of the present condition of the patient, 
and equally certain that, unless speedy relief was given, he must inevitably 
sink within a few hours, I determined to make an incision into the brain ; 
and, in the hope that my first impression about the fiuctuation had been cor- 
rect, and that, as I stated above, the removal of the tension had rendered the 
fluctuation indistinct again, I chose this place, where the brain was now 
already denuded of dura mater, and made an incision into the substance of 
the brain, about one inch in length and about half an inch in depth, which 
was followed instantaneously by a thick stream of healthy-looking pus ; further 
discharge was then favoured by gentle pressure on the dura mater, and by 
proper position of the head. I regret that, at the time, no means were taken 
to ascertain the exact quantity of the matter discharged ; but the circumstances, 
and the uncertainty of finding the matter, will easily account for that omission. 
The quantity was afterwards variously estimated by the different medical 
gentlemen present; several estimated it as high as five ounces, while the 
lowest estimate exceeded two ounces. The effect of the discharge was almost 
magical; for the patient immediately opened his eyes, put out his tongue 
when requested, and answered distinctly that he felt better; the pulse rose 
immediately to above 60 per minute. The wound was covered with warm 
water dressing, and the head placed as much as possible in a position to facili- 
tate the discharge. Absolute rest and water-gruel were recommended. 

The patient passed a quiet night, enjoying sound sleep; and awoke, com- 
fortable and refreshed, next morning. The woimd continued to discharge 
freely, and, in a few days, ail the incisions healed, leaving merely an opening 
to the extent to which the original scar, with the corresponding portion of the 
dura mater, had been removed. A probe introduced into the opening passed 
into a cavity of about three inches in diameter, extending nearly towards the 



90 Detmold^ Abscess in the Substance of the Brain. [Jan. 

median line. On account of a tendency of the opening to close, and cause the 
cavity to fill again with matter, a small tent of lint was introduced, and the 
warm water dressings continued. The patient was in every respect doing well ; 
sat up in bed at every dressing of the wound ; conversed freely ; was cheerful ; 
and had a good appetite. Therefore, no farther interference, with the excep- 
tion of a simple enema every third day, was deemed necessary : and, taking into 
consideration the length of time which had elapsed since the accident ; the 
comparatively slight suffering of the patient while carrying about this collection 
of matter ; the immediate and complete relief which the opening and dis- 
charge of the abscess had given him — together with the fact that the ante- 
rior lobe of the brain was the seat of the injury — I was sanguine in my 
prognosis, in spite of my friend Professor Dickson, who took a different view 
of the case. 

About the tenth day after the operation, the brain began to protrude where 
it was exposed, and, on the twelfth day, the hernia cerebri had reached the 
size of a large walnut. As the discharge from the abscess had considerably 
diminished, I determined to apply moderate pressure, which was effected in 
the following manner : I covered the protruding portion of the brain with 
lint, over which I applied thick compresses, which were held firmly down by 
broad strips of muslin, glued to the shaved head with collodion. The patient 
bore this amount of pressure well, and the discharge found its way through 
the dressing. Three days after, I removed the dressing, and found that the 
hernia cerebri had receded to a level with the integuments, showing a rosy 
and healthy granulating surface. The wound was now covered with a large 
and rather heavy warm poultice, which was kept in place by an elastic night- 
cap, making still a slight pressure ; and the danger from hernia cerebri seemed 
to be past. The exposed part of the brain began to cicatrize, and the patient 
was able to leave his bed about the eighteenth day after the opening of the 
abscess. Still, there was a small opening, which allowed the probe to pass 
into a cavity in the anterior lobe of the brain ; this cavity did not seem to 
show any inclination to fill up entirely, although the whole place where the 
bone was removed was deeply drawn in. 

About three weeks after the operation, although the patient was out of bed 
the greater part of the time, and, to the inquiry how he felt, answered generally 
"first rate,^' he began to lose his memory. This amnesia increased rapidly; 
so that, in a few days, he did not recollect either his own name or the names 
of his wife or children. When asked the name of his wife, he frequently 
answered Catherine, the name of his long-deceased mother ; but, when assisted 
by giving him the first two syllables, " E-li," he smiled, and readily answered 
Elizabetha. He recognized me, but did not recollect my name or my business. 
When I asked him whether I was a blacksmith or a shoemaker, or the like, 
he smiled, and said "No." When I asked whether I was the doctor, he readily 
replied, " Yes, the doctor." He would frequently, when asked a question, in- 
stead of answering, simply repeat the two or three last words of the question. 



1850.] Detmold, Abscess in the Substance of the Brain. 91 

It was remarkable to observe the attempt to recollect things, wbicb he would 
generally give up with a desponding shake of the head. Although he seemed 
to have forgotten all names, he recognized and recollected the name and value 
of money. Occasionally, however, he would call a dollar hundred cents, as 
though the word dollar had escaped his memory; yet he remembered the 
value, and substituted that, — a train of ideas which appears hardly compatible 
with such a complete loss of memory. A strange fact occurred about this 
time, of which, however, I was not an eye-witness. It was communi- 
cated to me by Dr. Miller. The weather getting cold, a stove was put up in 
the room; and he tried to explain to his brother that he had something at the 
workshop which he wished to be brought home ; but he did not recollect the 
name of the thing. He then took a piece of chalk, and tried to make himself 
understood by drawing the object. He at last succeeded in drawing a shovel, 
and, while thus engaged, he suddenly recollected the word, and described accu- 
rately the place where they would find it in the shop. At first, he wrote 
his name with comparative ease, although, when asked, he did not recollect 
it; soon after, when asked again to write it, he attempted it, but did not suc- 
ceed, although the letters were told him. He was also able at first to read, but 
soon lost that accomplishment, though not entirely, for, on days when he was 
brightest, he would still be able to read a few words. After having been 
asked several questions, and attempted to recollect things, his countenance 
assumed an expression of deep distress, evidently the result of mental fatigue, 
combined with the painful consciousness of loss of memory. His mental 
faculties were not always equal, but varied from day to day; they were always 
brightest immediately after the dressing of the wound and the emptying of 
the abscess. 

He continued in this condition till the 18th of October. The place where 
the bone had been removed had sunk in considerably, encouraging me in the 
hope that the cavity might close by the walls being thus brought close to- 
gether : but about that time the place again began to become more promi- 
nent ; the skin felt hot, and was red ; the patient was unwilling to leave his 
bed, and had an attack which, according to his wife's description, must have 
been something like a convulsive tremor; he also complained of headache. On 
the 22d of October, the parts had become very prominent, and the patient was 
in a condition approaching to stupor. As the probe could not be passed to 
the same depth as formerly, I concluded that the opening of the cavity had 
closed, and that a new accumulation of matter had taken place. I there- 
fore made another incision through the integuments into the brain, to the 
depth of one and a quarter inch, but without finding any pus. On this occa- 
sion, Professors Dickson and Grranville S. Pattison were present. There 
being no very urgent symptoms, these gentlemen agreed with me that it 
would not be prudent, for the present, to risk cutting deeper, as the inci- 
sion which I had made must have come very near the abscess, and as the 
matter might probably discharge spontaneously into the incision. But I 



92 Detmold, Abscess in the Substance of the Brain. [Jan. 

was much astonislied to find the patient, the next day, much better. His 
memory even was brighter than it had been for several days before this 
last incision, and the protrusion had sunk in, although, upon the closest 
examination, I could not discover that any matter had been discharged. On 
introducing the probe, it passed, to my utter astonishment, to a depth of 
four and a half inches into the brain, taking the direction of the lateral sinus, 
into which, evidently, the abscess had opened. Several medical men, among 
whom I may mention Dr. Gurdon Buck, Dr. Reese, Dr. Ashbel Smith of 
Texas, saw me pass the probe to that distance into the brain, and coincided 
with me in the opinion that it entered the lateral sinus. From that time, 
the patient again began to mend bodily; but he soon lost his memory en- 
tirely, though able to be part of the day out of bed. His appetite was good; 
he slept well; and did not complain. On the 26th of October, he had another 
rigor; he passed his urine involuntarily; vomited; and the outer walls of the 
cavity again commenced to protrude. On the 27th of October, he was speech- 
less; but would nod his head when asked a question, and put out his tongue 
when requested. He evinced intense pain upon the slightest pressure of the 
abdomen. On the 28th, all these symptoms had increased; and it was evi- 
dent that the scene was drawing to a close. I was, however, unwilling to 
give up the case without making one more effort; and, having come to the 
conviction that the present state was caused by an accumulation of matter in 
the lateral sinus, I determined to make an incision into the lateral sinus ; 
although, even if I succeeded in relieving the brain, the effusion which, from 
the tenderness of the abdomen, I feared had taken place in the peritoneal 
cavity, must prove fatal. 

About 12 o'clock, on the 28th of October, about sixteen weeks after the 
accident, and about seven weeks after I opened the first abscess, in presence of 
Di> Dickson, Dr. Miller, Dr. Ayres, Dr. Michaelis, Dr. Palmedo, and others, I 
made an incision through the most prominent part of the integuments, pene- 
trating fully an inch and a half into the substance of the brain, which appeared 
unchanged; but no pus followed the incision, although I thought, on withdraw- 
ing the knife, that its point was stained by pus. I then introduced a probe, 
which passed readily into the lateral sinus four and three-quarter inches deep; 
but, not finding any pus, I abandoned further interference. The patient having 
passed no urine in twenty-four hours, I introduced a catheter, but found the 
bladder empty. I now considered that I had gone as far as I could possibly 
justify; and we left the patient to his fate. We had been gone scarcely five 
minutes, when matter began to flow freely from the wound; and the nurse 
caught about ^ss of it in a glass. I went to see the patient again about 7 
0^ clock in the evening of the same day, and, just at the moment I entered the 
room, he calmly, and without a struggle, breathed his last. I was, of course, 
anxious to make an examination, but gained, with the greatest difficulty, the 
permission from the friends to examine merely the head on the same evening. 
I called upon Prof Dickson, Prof. Pattison, Dr. Bowen, and Dr. Miller; and. 



1850.] Detmold; Abscess in the Substance of the Brain. 93 

at mj request^ Prof. Pattison himself had the kindness to make the post- 
mortem^ two hours after death. 

After removing the upper part of the skull, all the edges of the fractured 
bone were found rounded off hy absorption, the dura mater in a congested 
state, the substance of the brain exhibiting on a cut surface rather more and 
larger red spots than normal; and, upon cutting down to the ventricles, both 
lateral ventricles were filled with a thin pus, the right ventricle containing a 
larger quantity than the left, which had partly discharged its contents before 
death through the wound. In the roof of the anterior corner of the left ven- 
tricle, a fresh incised wound was found, showing that I had, in the morning, 
carried my incision, as intended, into the ventricle. The uniting of the cut 
surfaces of the substance of the brain, immediately after the passage of 
the knife through it, had prevented the matter from being directly dis- 
charged. The septum pellucidum was broken down by suppuration. There 
was a deposit of lymph intermixed with pus upon the choroid plexus, and the 
same deposit could be traced through the third and fourth ventricle, making 
its appearance at the base. The supra-orbitar ridge was broken, and the whole 
left orbitar plate of the frontal bone was broken into small fragments. The 
abdomen was not opened. 

This case has evidently many points of interest, as well to the surgeon as to 
the physiologist and phrenologist. I abstain from all remarks upon the case, 
as all I might say will readily suggest itself to the reader; but, at the risk 
of repetition, I shall add a note, which Professor Dickson made of the case, 
and which he has allowed me to copy from his note-book. 

^' Francis Miller, a Glerman labourer, was struck by a falling derrick on the 
forehead. His skull was fractured; a piece of the bone above the inner third 
of the left eye was removed, and he recovered from the immediate effects of 
the accident. Some weeks afterwards, he became comatose ; and Dr. Detmold, 
being called by Dr. Miller, his original attendant, to see the case, removed, 
with prompt relief, another piece of bone. This Dr. D. showed me, with the 
remark, that a larger piece of the inner table had come away than of the 
outer, and that there would still be mischief Again Miller became comatose, 
and I accompanied Dr. D. to his residence. This was about nine weeks from 
the receipt of the blow. The patient, a stout, athletic German, lay prostrate; 
breathing slowly, laboriously, stertorously; his pulse was slow, about 50, and 
occasionally intermitting, or rather partially failing of impulse; the pupils of 
the eyes were sluggish, but did not absolutely refuse to contract on the ad- 
mission of light; the left being least impressible. He seemed insensible, and 
could not be roused to speak or move; by occasional restlessness, it appeared 
that there was no hemiplegia, or other form of paralysis ; his posture was not 
absolutely a passive one, but the fist was clenched, and the limbs somewhat 
contorted, and not readily yielding. I shall not describe the surgical opera- 
tion, which consisted in the removal of some large pieces of bone, leaving the 
No. XXXVn.— January, 1850. 7 



94 Betmold^ Abscess in the Suhstance of the Brain. [Jan. 

whole left forehead bare to within about an inch of the supraciliary ridge. 
This being done, the patient remained in the same condition, and Dr. D., 
avowing his full belief that compression was still kept up by the presence of 
matter within the substance of the brain, beneath the wide wound, announced 
his resolution to open the abscess, by cutting down through the cerebral sub- 
stance. No very positive or tenacious objection was made, but evident un- 
willingness to carry interference further at the time was shown by some of 
the medical gentlemen present. Dr. D., however, proceeded to make careful 
incision through the brain at a point where it was denuded of dura mater. 
It is uncertain what thickness of cerebral substance he cut through, from one- 
fourth to one-half inch perhaps, when pus began to flow. We estimated the 
amount discharged at from two to five ounces ; I thought it about three, rather 
less than more. The effect of this escape of matter upon the patient was 
highly gratifying. He had shown a certain degree of sensibility to the pain 
inflicted by the different operative processes, by a moan, or grimace, or move- 
ment of a limb, or more tightly clenching his fist -, but he now addressed his 
eye to any one who addressed him, put out his tongue when desired, and at 
last spoke, and said he was better. His pulse improved in regularity, and 
became more frequent, and his skin warmer. 

'^ Some days afterwards, I saw him again, and found a remarkable change 
in his condition; he shook hands with me, and conversed freely, though with 
some slowness. On my asking whether he spoke English, he replied that he 
had been fourteen years in this country. His appetite was good ; pulse full, 
between 60 and 70; eyelid of left eye swollen; eye bloodshot; skin about the 
wound looked puffy. 

^^ I visited him again, with Dr. Detmold, in about a fortnight. He looked 
dull and heavy, but brightened up, when a tent had been drawn from the 
wound, and a tablespoonful or so of pus let out ; his pulse about 60, soft and 
full. His memory was somewhat sluggish ; he had just dined, but had forgotten 
the materials of his meal. 

^^ To-day (October the 15th), I visited him with Dr. D. He was standing 
at the window, looking out, with one foot on a chair. His face was slightly 
flushed; his countenance and eyes somewhat heavy. He remembered his name 
Miller, but not his first name, Frank ; said it was William when I suggested 
it, but soon said no. Dr. Detmold he called Hopson, when asked who he 
was. Said he was not a carpenter — No! A doctor? No! A tailor? No! He 
could not remember his wife's name; and, after a few more questions, looking 
extremely fatigued, said, ^I am tired; it tires me.' He put his hand fre- 
quently to his forehead, with a puzzled air, shaking his head slowly and 
mournfully. He could not remember anything of a wound or blow upon his 
head. We seated him, and gave him pen and paper to write his name; but, 
after many attempts, he gave it up in despair. He said he could read, but 
kept his finger upon the words, and, looking down with many puzzled nods, 
at last muttered, ^ I cannot.' On being shown a half dollar, and asked what 

( 
r 



1850.] Reese's Notes of Hospital Practice. 95 

it was, lie said quickly ^ fifty cents/ A dollar bill being given him, lie fixed 
his attention upon the engraved words a good while, and then, with a grieved 
air, said '• he could not' — read, I suppose he meant. I am uncertain whether 
he knew what the paper was; Dr. D. thinks he did. His wife suggested the 
propriety of being grateful for the gift, upon which he nodded, and said 
^ Thank you.' I think he speaks English rather than German, for, being 
addressed once or twice in Grerman, he answered in English." 



Art. VIII. — Notes of Hospital Practice at Bellevue, New York. By D. 
Meredith Reese, M. D., Resident Physician. 

This institution is the great Charity Hospital, for the medical and surgical 
treatment of the pauper population of the city ; and, during the last two years, 
has provided for an average of nearly 600 patients. They are, for the most 
part, the victim.s of intemperance and vice, and only brought hither in very 
advanced stages of disease, too often only to die. Nevertheless, almost every 
variety of disease is here exhibited; and a single year, diligently improved by 
a residence in this hospital, on the part of a student, may prove the best clini- 
cal school to which a young practitioner can have access. Of these advan- 
tages several of the assistant physicians have availed themselves, and are 
already giving promise of professional eminence. 

In the following paper, it is proposed to record only a few of the practical 
and useful lessons either derived from experience here, or confirmed thereby. 

Typhus Fever. — -The opportunities for observing the results of medication, 
in cases of typhus or ship fever, have been ample, and perhaps unsurpassed 
in the country. It has been, however, only in the later periods of the malady 
that the patients have been admitted; very rarely, indeed, before the eighth 
day, and often much later, and not until complicated by some local mischief. 

It has been uniformly observed, that those patients who had been subjected 
to any active medical treatment before admission were in a worse condition 
than those in whom no medication had been previously resorted to. And 
whenever bleeding, purging, vomiting, &c. had been employed, before they 
were brought hither, the prognosis was unfavourable; and, with very few ex- 
ceptions, these cases proved fatal. How far the depraved constitutions of this 
class of patients may have rendered them unable to bear depletory remedies 
of any kind, even in the earlier stages of the fever, may not absolutely be 
affirmed ; but tUe fact of their being contra-indicated, and always mischievous, 
became apparent in all our cases. 

In regard to the treatment resorted to, no active means were employed, 
except when complications demanded a deviation from this rule ; or when diar- 
rhoea or erysipelatous inflammations supervened. These and other analogous 
sequoias were very rarely observed^ except in those cases which had previously 



96 '^QQ^Q^^ Notes of Hospital Practice, [Jan. 

been under medication before they reached the hospital, or in which pneumonia^ 
or some other form of the phlegmasise, had co-existed with the fever. The 
few cases which occurred as exceptions were traceable to too early and too 
liberal use of stimuli. 

Our usual course with the fever patients was to enjoin absolute rest in bed, 
with free ventilation, cool air, and warm drinks, the latter being nutritious, 
and occasional doses of the sp. mindereri, with or without a grain of ipecacu- 
anha, and continued until free perspiration was induced. When much heat 
prevailed, ice and iced water were found grateful, and, if necessary, the head, 
face, and neck were sponged occasionally with iced water. When diarrhoea 
or delirium was present, counter-irritants to the extremities and abdomen 
were relied on, which were always useful. And if, on the subsidence of the 
fever, after longer or shorter persistence, there was a flagging of the pulse, 
or other evidences of great prostration, wine whey, milk punch, with brandy 
and ammonia, were consecutively employed, and afterwards persevered in, 
according to the indications. The counter-irritation to the surface by mustard 
or epispastics was superadded, if delirium or any degree of coma was present. 

The only modifications of this treatment were — in complicated cases, or 
severe sequelae, cupping for pneumonia; injections of nitrate of silver for 
protracted diarrhoea; calomel, opium and ipecacuanha in combination for 
dysenteric symptoms: and for supervening erysipelas, the internal use of 
quinine and the external application of ice, nitrate of silver and blisters. 

Under the treatment thus described, we had the satisfaction of witnessing 
a degree of success which has rarely been exceeded by any other plan ; and, 
when the unfavourable condition of our patients when received is considered, 
the rate of mortality must be regarded as unusually small, the statistics of 
the hospital demonstrating that we lost less than one-sixth of our typhus cases, 
or about fifteen per cent. 

In our numerous dissections of the fatal cases, more or less efi'usion into 
the ventricles of the brain was almost uniformly discovered ; while the in- 
stances of intestinal ulcerations, or the morbid condition of Peyer's plates, &c., 
as described by the French writers, were but rare, and even then the cerebral 
mischiefs were more obvious and prominent. 

It may be proper to add that, during the continuance of our endemic, for 
such it was for many months, there was no evidence furnished which could 
be legitimately cited as favouring the theory that this fever was propagated 
by contagion ; but, contrariwise, the proofs were ample that it was not commu- 
nicable from person to person. For, although some of the nurses, and a 
few of the assistant physicians, contracted the disease while attending upon 
the fever wards, yet the same result would have followed, had intermittent 
or other malarious fever been prevalent ; not by contagion, but by the epidemic 
atmosphere to which they were exposed, under circumstances which constituted 
a predisposition to an attack. The generation and perpetuation of pestilential 
typhus in a ship, jail, or hospital, by the flagrant violation of the laws of 
hygiene too often exemplified under such circumstances, ought never to have 
been perverted into an argument to bolster up the theory of contagion, which 
else had long since been abandoned among the relics of barbarism, from which 
enlightened science and rational medicine ought wholly to hav^ escaped. 

Burns. — Among the most numerous cases brought into the surgical wards 
of charity hospitals everywhere, may be reckoned the injuries received by 
burns and scalds, which, when extensive, are too often fatal. In the treatment 
of these injuries, we have had great experience and uniform success, when the 



1850.] Reese's Notes of Hospital Practice. 97 

patients were brought in soon after the injury. No fatal case of recent burn 
or scald has occurred in the hospital^ although several have been extensive 
and severe. The universal treatment of all such cases is to cover the parts 
with wheaten flour thrown over the wounds by a dredging-box^ which, if 
thoroughly done so as to exclude the air, and prevent its temperature from 
reaching the suffering tissues, will afford instant relief from pain, and allay 
all that nervous irritation which is the chief source of immediate danger in 
all cases of extensive burns. We have had opportunity to test this practice 
in terrible burns occasioned by explosions of gunpowder, in scalds from the 
bursting of steam-boilers, in examples of persons while drunk falling into the 
fire, and others in which the clothes were burnt off the body by the combus- 
tion of spirit gas, &c. In all these cases, and in some of them scarcely any 
portion of the body had escaped — and notwithstanding, in a few of them, the 
integuments were literally baked, so that extensive and deep-seated suppura- 
tion and sloughing were inevitable, and had afterwards to be endured — the 
external application of the flour was in the first instance our only remedy, 
and this was continued for one or more days while the acute effects of the 
injury demanded it. The superficial portions of the burn or scald would 
often heal under this application alone; and the solutions of continuity, more 
or less deep, which remained open and discharging, were then dressed with 
lime-water and oil, by means of a feather, to which creasote was added if the 
granulations were slow, or the sloughs tardy in becoming loose. Under this 
dressing, the most formidable burns have been healed ; and, even when the face 
has been involved, there has been scarcely any considerable deformity. In one 
of our patients, the face being horribly burned by an accidental explosion of 
gunpowder, the grains of powder having been imbedded in the skin, very great 
apprehensions were indulged that the discoloration thus produced would per- 
manently disfigure and deform the countenance. But, after the persistent 
application of the flour for three successive days, and until the tumefaction of 
the face and head had subsided, it was found that, with a few applications of 
the lime-water dressing, the cicatrization was complete, and even the discolor- 
ation was removed. 

If this simple remedy were resorted to in the severe scalds sometimes oc- 
curing from explosions of steamboat boilers, &c., there can be little doubt that 
the fatality of such burns would be very rare; while the popular and mis- 
chievous methods of applying raw cotton, oil, molasses, salt, alcohol, spirits 
of turpentine, sugar of lead water, ice, &c. to extensive and deep hums, are all 
of them injurious, and often destructive to life. 

SypMlis. — A large majority of the surgical diseases found in this hospital 
are constitutional syphilis, in the secondary or tertiary forms. Among these, 
cases of iritis are frequent, and are generally cured by mercurials and opium 
internally. Periostitis, in every form and location of nodes, is very generally 
removed by the iodides and arsenic, the latter often successful after the former 
fails. Rupia yields to large doses of the iodide potassae, with corros. subli- 
mate, or in some cases without it. The iodide of quinine has been found 
useful both in secondary and tertiary syphilis; nor, indeed, has any form of this 
terrible malady been found irremediable, except when the larynx and trachea 
have extensively suffered. In one case, tracheotomy was resorted to, without, 
however, any other than temporary relief. It is scarcely necessary to add that, 
apart from the medication above named, very great reliance is placed, in con- 
stitutional syphilis, upon liberal and even generous diet. 



98 Reese's Notes of Hospital Practice. . [Jan. 

Pedicular Disease. — This affection is happily rare in this country; but a few 
cases have occurred in the hospital, one of which was as remarkable as any 
recorded in the foreign books. The patient was not merely covered with 
living lice upon every square inch of his body, but they were constantly issuing 
from the pores of his cuticle, beneath which they existed in incredible num- 
bers. By scraping any part of his skin with a stick, or any other solid body, 
hundreds of living lice would fall out of the abraded cuticle, and might be 
collected upon a sheet of paper, as was several times done, for exhibition to 
visitors. In other respects, the man was in tolerable health, but so stupid 
that but little of his history could be learned, and nothing of the origin or 
duration of the disease. He was cured by the external application of dilute 
ung. nitr. hydrarg., with a very slight ptyalism. 

Elephantiasis. — Several cases of this formidable disease have been presented, 
but not one of them was in a state admitting of successful treatment. The 
most remarkable of them was in a woman of immense size, said to weigh four 
hundred and jQfty pounds. With the characteristic degeneration of the skin 
of the abdomen, thighs, and legs which belongs to this malady, she suffered 
under ascites, and died soon after entering the hospital. Such was her obe- 
sity that the abdominal walls were found to be of the thickness of five inches, 
and the fatty deposits about the heart measured two inches in thickness. 

Acute Rheumatism. — This disease has been successfully treated in numerous 
cases by large doses of nitrate of potash, Ji to 5^j having been given and re- 
peated every few hours. No bad symptoms followed in any case, but it failed 
sometimes, when the colchicum afterwards succeeded. Our experience has 
not been sufficient, however, to determine upon the comparative merits of this 
plan of treatment. 

Phthisis Pulmonalis. — The advanced period of tuberculous phthisis, in 
which most of our patients reach the hospital, affords but slender encourage- 
ment from medication. In those, however, with whom any rational hope 
could be indulged from treatment of any kind, the cod-liver oil has been fre- 
quently and extensively employed, and many of the patients have improved 
under its use, and been discharged from the hospital, so that their subsequent 
history could not be traced. The apparent effects have been an improvement 
in the appetite and strength; diminution of cough, expectoration, diarrhoea, 
and night sweats, with the establishment of regularity in the alvine evacua- 
tions; but further experience will be required to estimate accurately the 
powers of the remedy. The crude and clarified oil have both been tried, 
though preference is given to the latter. From a teaspoonful to a tablespoon- 
ful has been given three times a-day. 

Erysipelas. — During every winter, and at times when an unusual amount 
of humidity prevails, there has been, in the surgical wards, and sometimes 
simultaneously in every part of the hospital, a marked tendency to erysipela- 
tous inflammation, so that occasionally it may be said to approach an epidemic 
form. It has then been deemed expedient to collect all the cases scattered 
over the house into one or more wards, rather for the facility of theii' treat- 
ment than from any dread of contagion. Ice and iced water have been found 
to be invaluable as a local application, and this, when the free application of 
nitrate of silver, iodine, and blisters failed to arrest the inflammation, or pre- 



1850.] 'Rqq^q^% Notes of Hospital Practice. 99 

vent its spreading. The constitutional treatment has been chiefly quinine, 
wine, &c., under which a majority of our patients recovered. In phlegmon- 
ous erysipelas, numerous and extensive scarifications, allowing of the free 
escape of the pus, together with moderate but unremitting pressure by rollers, 
have proved signally successful in many formidable cases — appropriate con- 
stitutional treatment, to support vitality, having been steadily persevered in 
throughout. 

Puerperal Peritonitis. — A sudden irruption of this fever has appeared, in 
the lying-in wards, several different times, the epidemic character of which 
has been in every instance promptly arrested by abruptly changing the apart- 
ments to another floor of the house, having a difierent exposure to the external 
air, and in which a due ventilation could be secured. The wards in which 
the fever appeared were meanwhile thoroughly cleansed and purified by white- 
washing, &c., and not until thoroughly aired and renewed by a change of 
furniture and bedding, have they been again occupied. Two or three weeks 
have been found a sufiicient time to vacate the wards, under such circumstances. 
The medical treatment has been various, and in rather more than half of our 
cases unsuccessful. The opium practice, when exclusively relied on, has uni- 
formly failed. In no case has recovery taken place without bleeding, and 
yet, in several well-remembered examples, no advantage was derived from 
either venesection or leeching, although both had been liberally and judiciously 
employed. The same may be said of the mercurial treatment, with and with- 
out opium, and blood-letting, although all these remedies were used in every 
example of recovery; yet, in some instances, they all failed. The most 
numerous instances of success, however, were in those patients who, duriog 
the epidemic, were treated as follows : Immediately after delivery, a combina- 
tion of ten grains of calomel with ten of camphor was given. On the appear- 
ance of the characteristic rigor, when this occurred, or when without it other 
symptoms indicated an attack, the same dose was repeated with two grains of 
opium. When pain and tenderness became distressing, and in the onset of 
the febrile excitement, a full bleeding at the arm was resorted to, the patient 
being placed in an erect position, and approaching deliquium being secured. 
If but little relief to the pain and tenderness followed this remedy, or these 
symptoms speedily returned, twenty or more leeches were applied to the 
abdomen, and, meanwhile, calomel and opium, in doses usually of from five to 
ten grains of the former, and one to two grains of the latter, were repeated 
every three or four hours ', and in urgent cases more frequently. In these 
circumstances, a large blister plaster, covering the abdomen, and dressed with 
mercurial ointment on its removal, was found signally beneficial in several 
examples. The ptyalism, when it occurred under this treatment, was but 
slight, and in no instance severe. The patients who recovered under this 
treatment used ice and iced water freely, all their drinks being cooled with 
ice. The extent to which bleeding was carried was various; two or three 
full venesections, besides leeching, having been sometimes called for during 
the first twenty-four hours, and with uniform advantage, as the results proved. 
So also the calomel was varied in dose, and in the aggregate cjuantity, accord- 
ing to circumstances. Small and even very minute doses, often repeated, were 
relied on in several cases; but every one of these proved fatal. So also 
scruple doses, with and without opium, and venesection were tried, but with 
less favourable results than the course above mentioned. 



100 'KeQm^ B Notes of Hospital Practice. ' [Jan. 

Chloroform and Ether. — The employment of these anaesthetic agents by 
inhalation has been signally successful in every department of hospital ser- 
vice. At first^ and immediately after its introduction into the Massachusetts 
Greneral Hospital, the ether was used in all surgical operations of any magni- 
tude, and in various painful and spasmodic diseases. No permanent evil 
effects followed, except in a single instance in which cerebral disease, probably 
of organic character, had pre-existed, and in this case the operation for the 
removal of extensive exostosis was necessarily tedious, and the inhalation 
had to be continued, and more than once repeated. The wound healed kindly, 
but the patient had to be subsequently sent to the insane department, and is 
deemed incurable. As, however, he had exhibited indications of insanity 
long prior to the inhalation, the mischief cannot fairly be ascribed to the 
etherization, although it would be indiscreet to employ this agent in any 
similar case. In no other instance did any evil happen which could be 
legitimately traced to the use of ether, although it was used very frequently 
for months, and until the introduction of chloroform. 

This latter article was adopted as a substitute for the ether, as soon as 
authentic accounts were received of its employment by Dr. Simpson with 
success, and chiefly because we had found that the effects of ether were too 
slow in some cases, unequal in degree in others, while it occasionally failed. 
The chloroform used at first was prepared by Dr. John Miller, then 
chemist and apothecary to the hospital, and was of entire purity and great 
strength. Our early experience with it developed two objections to its use; 
namely, it was sometimes too rapid in its action, occasionally cumulative, 
and deep anaesthesia came on too suddenly ; hence we used it with great 
caution, and closely watched its effects. Anxious to avail ourselves of its 
greater certainty than ether, and yet avoid too deep anaesthetic effects, we 
determined to dilute the chloroform with ether, in the proportion of two 
measures of the latter, by weight, to one of the former. With this mixture, 
we have had every reason to be satisfied, and have hence very rarely employed 
the chloroform alone. The suggestion of this mode of dilution was first 
made by Dr. W. H. Van Buren, one of the visiting surgeons, and at his instance 
it was prepared and used for a surgical operation, with such entire success 
that we have employed this mixture ever since. In some instances, it is true, 
we have found patients so unsusceptible, that we have resorted to the chloro- 
form alone, until the desired insensibility was produced, and then rendered 
the effect persistent, as long as necessary, by using the mixture of chloroform 
and ether, regarding it as a safer practice, and equally efficacious to this end. 

Our method of employing these agents has been either by applying to the 
mouth and nostrils a hollowed sponge, moistened with Ji or 5ij of chloroform, 
or 5SS of the mixture; or, by means of a towel or handkerchief in lieu of the 
sponge, and which, on some accounts, is to be preferred. In no case, have we 
persisted continuously to apply either of these agents, so as to exclude the 
atmospheric air, but have always allowed the alternate inhalation of the air and * 
that of the chloroform or ether. And our rule has been to remove the agent f,yj^ 
from the mouth and nostrils as soon as anaesthetic effects have become manifest, 
reapplying the sponge or towel occasionally, if necessary. With these precau- 
tions, our experience has been so entirely free from any untoward or unplea- 
sant consequences, that we can scarcely feel the force of the objections recently- 
urged against an93sthetic agents, and are constrained to apprehend that the 
mischiefs described have resulted either from the want of due caution in their 
employment, or the lack of discrimination in the subjects, by overlooking ex- 



1850.] 'Ree^Q^B Notes of Hospital Practice. 101 

isting pathological states which contraindicate their use. Certainly^ we can 
have no sympathy with the surgeon whose unsuccessful operations are ascribed 
by himself to etherization ) much less is any man authorized to attribute the 
want of success in another^ to the fact that either chloroform or ether had 
been used in the case. 

The following are a few of the specialities in which these agents have been 
employed here ; namely : — 

1st. In reducing dislocations; and here our experience has proved the in- 
valuable importance of the discovery which has furnished to the profession 
these means of completely relaxing the muscles and ligaments of the larger 
joints. In several instances^ luxations at the shoulder and hip of long dura- 
tion^ which, after repeated trials, could not be reduced by any amount of phy- 
sical force applied in the ordinary way, were, after the inhalation of chloro- 
form by the patient, found capable of ready reduction with the thumb and 
finger. If no other good were conferred by chloroform, this alone would 
render the discoverer a benefactor to the world. 

2d. In hysterical, epileptic, and puerperal convulsions, we have had fre- 
quent opportunities of witnessing the speedy and effectual relief afforded by 
the inhalation of chloroform and ether ', and, in the latter of these forms of 
disease, after extensive venesection and the other most potent antispasmodics 
had been tried in vain. 

3d. In delirium tremens, we have frequently been able permanently to 
calm a violent patient, and induce profound and protracted sleep, after both 
lupuline and opium 'had failed. 

4th. In paroxysmal or spasmodic asthma, a very few inhalations of ether 
or chloroform, without even approaching full anaesthesia, will be found more 
effectual for relief than any other remedy. 

In tedious, protracted, or severe labour pains, and especially when mal- 
presentation, or other causes, render painful operations necessary, whether 
manual or instrumental, the inhalation of chloroform, with the precautions 
already named, has been found to be uniformly safe, and pre-eminently useful, 
both to the mother and child; while it divests the most formidable operations 
of obstetric surgery of their terrors, alike to the physician and his patient. 
We have not encouraged the use of this agency in natural labours, unattended 
by any considerable severity, although in these 'cases no evil has happened to 
mother or child in our hands. But, in all cases in which it has become im- 
portant to lessen the sufferings of the mother, we have uniformly administered 
the chloroform, and have had every reason for undiminished confidence in its 
innocence and utility. Indeed, we had good ground to believe that, in several 
cases, our patient would have died undelivered, if we had been without chloro- 
form; and yet, in more than one of these, the child as well as the mother was 
saved. Nor have we been able to detect, in a single instance, any subsidence 
or diminution of the labour pains, either in frequency or force, during the 
moderate degree of anaesthesia, which is all that is necessary for any useful 
purpose in obstetrical practice. And yet we have been obliged, in some severe 
labours, to continue the repetition of the inhalation during several hours — ap- 
' plying the chloroform to the nostrils and mouth for a few moments only, how- 
ever, at the commencement of every pain — our patient importunately pleading 
for it, after having felt its efficacy in relieving her sufferings. Such has beeu 
our hospital experience in certainly one of the largest lying-in departments in 
our country. 

Surgical Operations. — In all cases, when the severe or formidable operations 
of surgery have been called for, whether by the knife, saw, chisel, or red hot 



102 '^QQ^Qi ^ Notes of Hospital Practice. [Jan. 

iron, we have not hesitated to give our patients the benefit of chloroform ; 
and, in all this variety of infliction, we have witnessed entire immunity from 
pain, and in most cases there has been no consciousness of the operation. The 
limb has remained unheld and unmoved while the actual cautery has been made 
repeatedly to traverse a joint; and, in one instance of the amputation of a 
thigh, the patient remained ignorant of his mutilation until the fifth day, when 
it became necessary to dress the stump, he all the while supposing that his 
leg was bound up m splints, and complaining of that very common, though im- 
aginary, sensation in the toes of the amputated limb. The success of opera- 
tions, and the early healing of the wounds thus made, have in no instance been 
hindered or delayed, so far as we could perceive ; and we have even surmised 
the contrary. In primary amputations, after compound or comminuted frac- 
tures, when these are judged necessary, the additional shock to the nervous 
system, so much dreaded, is in a great measure obviated by the judicious use of 
chloroform. And, whatever may be the prejudice existing or engendered by 
panic-makers, who are for the most part mere theorists, the extensive expe- 
rience and success of practical men, here and elsewhere, should disabuse the 
profession and the public of the erroneous views which have been promulgated 
of late, on the^ basis of a few unsuccessful and probably indiscreet experiments, 
and isolated cases of unfortunate termination. The profession should not 
only allow their patients the advantages derived from this new agency to 
protect them from suffering, but they should feel that they are not at liberty 
to hazard the safety of their patients by withholding from sufferers of every 
class the benefit of anaesthesia, now that science has conferred this boon upon 
afflicted humanity. 

Cholera. — During the recent epidemic by which our city and its vicinity so 
severely suffered, there were but very few cases at Bellevue, notwithstanding 
the large number of patients here, and of a class signally predisposed to be- 
come its victims. The preventive measures relied on were, a strict attention 
to cleanliness in and about the entire premises ; thorough and persevering 
ventilation of all the wards ; the extensive use of ice and iced water ; and a 
careful regulation of the dietary habits of all the inmates. Grood dry sugar 
was at once substituted for molasses, and better supplies of food, both in 
quantity and quality, were forthwith provided. Very little medication of any 
kind was permitted, and all cathartics were forbidden. When the premoni- 
tory diarrhoea began to exhibit itself, it was made the duty of the orderly or 
nurse of every ward to notify the assistant physicians of every instance in 
which looseness of the bowels was observed ; and, at stated hours, a medical 
inspection of all the patients was made both day and night to detect the ear- 
liest symptoms, which there was a disposition to conceal. The prescribed 
antidotes were placed in every ward, to be in readiness at all times ; and all the 
inmates were instructed in the importance of early treatment in case of an 
attack. 

For several weeks, and even after the neighbouring institutions on Black- 
welFs Island were visited with the epidemic, the hospital at Bellevue had 
wholly escaped ; nor is it probable that we should have had a single case, had 
not the atmosphere of the entire premises been rendered impure and offensive 
to the last degree by the contents of the dead-house for the whole city, which 
is most improvidently located within a few yards of the hospital. At the 
climax of the epidemic, more than a hundred bodies were deposited here 
in a single day, whence they were to be transported in boats to ^^ Potter's field.'^ 



1850.] B^eese's Notes of Hospital Practice. 103 

But the means of removal being inadequately provided, they were allowed 
to accumulate; and the effluvia became so offensive, that it was necessary 
to close all the windows opening towards the dead-house; and even then the 
stench was intolerable. All ventilation of the wards being thus precluded, 
one, and then another, case of cholera began to appear, and the premonitory 
diarrhoea now became almost universal throughout the house, a score or more 
being thus seized in a single night. 

It was not until a number of deaths had occurred, including the keeper of 
the dead-house, and the gate-keeper who was located near it, that our remon- 
strances were heard; and the necessary provision to empty the dead-house, by 
removing the bodies every evening, could only then be obtained. From that 
time, the cases were few, and occurred at intervals of several days, so that all 
apprehensions of its becoming epidemic here were at an end. The whole 
number of cases during the summer did not exceed thirty, and several of 
these were brought hither. The persons attacked were chiefly broken down 
previously by age, intemperance, or chronic disease of long standing, so that 
a majority of all the collapsed cases were fatal. Several of them had no pre- 
monitory symptoms whatever, while others concealed their symptoms until 
in a hopeless condition. The few recoveries were in persons who were treated 
internally by large doses of calomel, repeated every two to three hours, vary- 
ing from ten to twenty grains, and usually in combination with capsicum, or 
camphor, or both; large quantities of ice were eaten, meanwhile, and the sur- 
face of the body covered with heat and stimulants. In other cases, however, 
it must be conceded that this identical treatment failed; but without it, none 
recovered. A slight ptyalism followed in three cases, one of which afterwards 
died of consecutive fever. Only two of our cases were bled, and one of these 
recovered. I have notes of all the cases, numbering twenty-nine, of whom 
eight only were saved. 

Our success in arresting the diarrhoea was very nearly universal; and, in- 
deed, only one case of death occurred when the premonitory symptoms were 
discovered. There was no novelty in the treatment of these — our reliance 
being chiefly on rest, ice internally, with heat to the skin, and an occasional 
dose of ether, sp. lavend. c, and vinum opii, mixed in suitable proportions, 
which was found sufficiently astringent, cordial, and anodyne for our purpose. 
The tinct. capsicum was occasionally tried in various combinations, but was 
found to offend the stomach, so that even laudanum was rejected when mixed 
with it, and retained only when given alone. 

The epidemic prevailed extensively upon BlackwelFs Island in each of the 
institutions located there, and was very fatal. I am not in possession of the 
facts in relation to its prevalence at the Penitentiary or Almshouse ; but one 
of my assistants. Dr. H. D. Jenkins, having been detailed from Bellevue to 
aid Dr. Ranney at the Lunatic Asylum, I append to this paper the tabular 
statement made by him, which may be relied on as accurate, and is, perhaps, 
worthy of publication in your Journal, as, for all practical purposeSj it is suffi- 
ciently minute. 



104 



Reese's Notes of Hospital Practice. 



[Jan. 



Dates 


Name 


Purg- 
ing 


Vomit- 
ing 


Cramps 


Pulse 


Treatment 


June 10 


Boon 


slight 


none 


severe 


none 


cal. gr. X, opii gr. i, every half h. 


" 12 


Margaret Help 


" 


u 


" 


feeble 


a a 11 il 


" 23 


John Crogan 


" 


" 


" 


none 


cal. gr. X every h. ; injecs. tr. op. 


'^ 24 


Hannah Walden 


" 


ii 


" 


none 


" " sodae acid. tart. 


" 26 


Catrene 


none 


il 


" 


none 


quin. ferri acid. sul. arom. 


u u 


Marg'ret Flanighan 


" 


ii 


nat- 


feeble 


pil. pi. op. every half hr., brandy 


U li 

u u 


Humey Boleld 
Ann DufFy 
Mary Smith 


u 


ii 
li 


u 


none 
none 
none 


cal. gr. X every half hour 

a il a 

effer. draughts ; laudanum ; quin. 
et capsic. 


« 27 


Rose Shaughnessy 


" 


ii 


ii 


feeble 


prep, camph. every hour 




Smith, nurse 
Mary Marteneau 


11 


ii 
li 


" 


feeble 
none 


cal. XX gr. every hour 

" " " 5 times 


u u 


Amelia Jacobs 
Rose Larkin 


" 


li 


u 


none 
feeble 


prep, camph. every hour 
mustard emetic, brandy, tr. op. 
ether sulph. 


'' 28 


Ellen Murphy 


11 


ii 


" 


feeble 


cal. gr. XV every 2 hrs. prep. cam. 


" 29 


Ann Scandlen 
Bridget Whalen 


u 


ii 
11 


il 


feebfe 
none 


caL gr. XX every 2 hrs., brandy 
cal. g. X every hour; mist. arom. 


<( u 


Peter Nicholson 

Alex. Jack 
Rebecca Saul 


11 


il 

li 


11 
ii 


feeble 

feeble 
feeble 


cal. gr. XX every 2 hrs. " " 

cal. gr. X every hour " " 
cal. XX by 10 every h. " brandy 


" 30 


Bridget McGuire 
Harriet McCarty 


il 


ii 




feeble 
feeble 


U 11 11 (( 

cal. gr. X every hour 


July 1 


Jane Loyd 


li 


" 


ii 


feeble 


cal. gr. XV every 2 hrs. " 


a 2 


Anne Curly 


tl 


" 


ii 


none 


cal. gr. XX ax every h. " 
sul. quin. 


" 3 

U it. 

a li 

U li 

li ii 


Lauretz Burtz 
Phebe Earle 
Phcebe Hulet 
Prisoner, blk. fem. 
Eliza 


It. 

il 

ii 


ii 

ii 
ii 


;| 


feeble 
feeble 
feeble 
feeble 
none 


cal. gr. X every hour " 
cal. gr. XXX by 10 every hour 
cal. gr. XX every 2 hours 
cal. gr. X every 2 hours 
cal. gr. i, tinct. opii 


li tc 


Mrs. Franks 


" 


" 


u 


feebfe 


cal. gr. i every 10 min. ; tinct. 
opii gtt. iv 


a 4 


Wm. Cain 


11 


(( 


a 


feeble 


li U (( 


« SlMarg. Callahan 


11 


£J 


j; 


feeble 


li 11 11 


" "Bridget Scott 


11 


ii 


il 


none 


il u u 


" "{Charles Carroll 


11 


ii 


ii 


feeble 


cal. gr. X every hour 


'' 7jMrs. Henry 


" 


ii 


none 


feeble 


prep, camph. every 2 hours 


^' "|Mary Daily 


li 


ii 




feeble 


U U U li 


" " Susan Mason 


11 


" 


a 


none 


cal. gr. i, tinct. opii gtt. iij 


" " Cath. Lynch 


11 


t£ 


li 


feeble 


" " " V.S. oz. xi 


" "jAnn Riley 


ii 


il 


il 


feeble 


cal. gr. X every hour 


" 8 Hannah Ray 
" "Leonard Willet 


■ ' 


il 


a 


none 


cal. gr. i; tinct. opii 


«< 


ii 


a 


none 


cal. gr. XX by x every hour 


" "Michael Bromley 


li 


ii 


a 


none 


U il 11 il ii 


" " Wm. H. Knapp 


il 


il 


u 


feeble 


prep, camph. oz. ss., cal. gr. x 
every hour 


" ", Susan Taylor 


li 


li 


u 


none 


cal. gr. X by gr. i every h.; tr. op. 


" "jMrs. Adams 


il 


ii 


a 


none 


ii ii il u 


" " Owen Brady 


11 


ii 


a 


none 


ca,l. gr. X every h. ; V.S. oz. viij 


" " Barnabas Larkin 


ii 


11 


a 


feeble cal. gr. x by i ; tinct. opiigtt. iv | 


" " Mich. Hanley 


il 


tl 


a 


feebfe 


<( U .11 11 


" "iMrs. Spyer 


11 


ii 


slight 


feebfe 


prep, camph., cal. gr. x 


" 9 Mary McCormick 


ii 


" 


" 


feeble 


cal. gr. X every hour 


" " Sarah Wood 


11 


il 


" 


none 


cal. gr. xby i.; tr. opii 


" " Susan Katon 


ii 


ii 


none 


feebfe 


cal. gr. X every hour 


« " George 


ii 


ii 


" 


none 


cal. gr. XX by x every hour 


" "i Valentine Joe 


il 


ii 


" 


none 


cal. gr. X every hour 


" " Rosanna, blk. 


ii 


il 


a 


none 


U li ii 


U 11 


M. Leonard 


li 


ii 


il 


none 


cal. gr. XX every 2 hours, mist, 
camph. 


11 11 


Eliza Kellburn 


li 


" 


il 


feebfe 


cal. gr. ij, tr. op. every 10 min. 



1850.] 



Reese^s Notes of Hospital Practice. 



105 



Result 


Duration 


Previous 
sympt's 


Collapsed 


Remarks 


died 


5i hours 


none 


immediately 




recovered 




none 


partial 


Diarrhoea for 2 days. 


died 


12 hours 


none 


total 


Diarrhoea for 24 hours. 


died 


15 hours 


none 


in 2 hours 




died 


3i hours 


none 


immediately 




died 


12 hours 


unknown 


before death 




died 


10 hours 


none 


immediately 




died 


12 hours 


none 


imiTiediately 




died 


18 hours 


unknown 


immediately 




recovered 24 hours 


unknown 


not 




recovered 48 hours 


unknown 


not 


Diarrhoea for 12 hours. 


recovered 6 days 


unknown 


in 2 hours 


Continued in collapse 12 hours. 


died 


36 hours 


unknown 


from first 


Slight reaction. 


died 


11 hours 


unknown 


in 3 hours 




recovered 


12 hours 


unknown 


partial 


Diarrhoea for a day. 


died 


30 hours 


none 


in 2 hours 


Reaction came on in 12 hours, but relapsed. 


died 


18 hours 


none 


in 2 hours 


No reaction. Bilious vomiting in 2 hours. 


died 


6 days 


none 


partial 


Diarrhoea 12 hours; reaction in 12 hours; se- 
condary fever. 


recovered 12 hours 


none 


partial 


Diarrhoea 24 hours ; reaction in 6 hours. 


died 


15 hours 


none 


in 4 hours 




died 


6 days 


none 


immediately 


Diarrhoea 2 days ; reaction in 12 hours ; second- 
ary fever. 


recovered 


12 hours 


24 hrs. 


not 




died 


4 days 


unknown 


in 4 hours 


Reaction in 10 hours ; secondary fever. 


died 


3 days 


none 


immediately 


Partial reaction in 14 hours. 


died 


14 hours 


none 


in 4 hours 


Diarrhoea for 18 hours ; coma. 


recovered 14 hours 


unlvnown 


after attack 


Collapse lasted 10 hrs. ; bilious diar. ; ptyalism. 


died 


3 days 


unknown 


after attack 


Collapse lasted 6 hours ; ptyalism. 


died 


24 hours 


unknown 


in 10 hours 


Diarrhoea 12 hours. 


died 


5 days 


none 


immediately 


Collapse continued 12 hrs.; died of second'ry 

fever. 
Diarrhoea 2 days. 


recovered 


10 hours 


none 


not 


recovered 




unknown 


in 4 hours 


Collapse continued 10 hours; bilious vomiting 
and purging; ptyalism. 


died 


15 hours 


unknown 


in 3 hours 




died 


7 davs 


unknown 


immediately 


Diarrhoea 12 hrs. ; ptyalised. 


recovered 24 hours 


unknown 


not 


Bile in discharges in 12 hours. 


died 1 16 hours 


unknown 


in 6 hours 




recovered 12 hours 


unknown 


not 


Diarrhoea for a day. 


died 


2 days 


unknown 


immediately 


Diarrhoea for 12 hours ; partial reaction in 6 
hours ; relapsed 12 hours afterward. 


died 


26 hours 


unknown 


in 4 hours 


Partial reaction in 12 hours. 


recovered 24 hours 


none 


not 


Bilious discharges. 


died 


25 hours 


none 


immediately 


Partial reaction in 4 hrs. ; sank ; bilious vomiting. 


died 


4 hours 


none 


immediately 


No effort towards reaction. 


died 


3 hours 


none 


immediately 


a a u 


died 


30 hours 


none 


in 6 hours 


Bilious vomiting. 


died 


6 hours 


none 


immediately 




died 


8 hours 


none 


immediately 


Vomiting and purging continued two hours. 


died 


16 hours 


none 


immediately 




recovered 


2 days 


none 


not 


Bilious discharges. 


recovered 


2 days 


none 


not 


u a 


recovered 


2 days 


none 


not 




recovered 


Iday 


none 


partial 


Ptyalism. 


died 


26 hours 


unknown 


immediately 




died 


6 days 


unknown 


partial 


Bilious vomiting continued 3 days. 


died 


20 hours 


unknown 


immediately 




died 


9 hours 


none 


immediately 




died 


17 hours 


unknown 


immediately 




died 


12 hours 


unknown 


immediately 




died 


2 days 


unknown 


partial 


Reacted, but collapsed afterwards. 



106 



Reese's Notes of Hospital Practice. 



[Jan. 



Dates 


Name 


Purg- 
ing 


t 
Vomit- 
ing 


Cramps 


Pulse 
feeble 


Treatment 


July 8 George Johnson | 


none 


none 


none 


cal. gr. x, twice 


U U( 


jreorge Kern 


a 


" 


ti 


feeble 


cal. gr. X every h.; prep. camp. 


u <J 


Cath. Withers 


u 


il 


" 


feeble 


cal. gr. X, mist, aromat. 


" lo: 

a u 


Mason 
Eliza Koach 
Jerush. Myers 


il 


(( 


II 


none 

feeble 

feeble 


cal. gr. XX every 2 hours 
cal. gr. X by gr. i every hour 
mist, aromat. dr. i every hour 




Connar 
Helen Whalin 


'' 


il 
11 


a 


feeble 
feeble 


cal. gr. X every— V.S. ad oz. xij 
cal. gr. XX bygr. i; mist, arom., 
efier. draughts 


a a \ 


Margaret O'Neil 


a 


li 


abdo'en 


feeble 


cal. gr. X every h. " " 


li a 


Freson 


" 


" 


none 


feeble 


cal. gr. X '^ , " " 


(( a 


Capt.F.AV.Lexton 


il 


li 


(( 


feeble 


cal. gr. X " " " 


U ti 


Julia Slater 


«' 


il 


li 


feeble 


cal. gr. X " mist. arom. 


li « 


Barba. Clinman 


a 


li 


il 


none 


cal. gr. i ; tinct. opii 


'< 11 

(( u 


Julia Ferris 
John Hoewick 
Harriet Vanderson 


il 


11 


li 
il 


none 

feeble 

none 


cal. gr. i, tinct. opii gtt. ij 


u a 


K. K. President 


<< 


u 


a 


none 


cal. gr. X every hour 


" 12 


Timothy Grey 
Elizabeth Deal 


^' 


il 


" 


feeble 
feeble 


" " " prep. cam. 
cal. gr. X every hour 


a u 


Mary Patterfield 
Rose Goerch 


li 


ii 


a 


none 
feeble 


cal. gr. X " prep, camph. 
cal. gr. X " " " 


U li 
U il 


O'Neil 
Cath. Atte 


u 


il 


- 


feeble 
feeble 


cal. gr. XX by X every h., prep, 
camph. 


" 13 

il li 

il li 
il 11 

11 11 
11 11 

11 a 


Joseph Carneen 
James Cassidy 

Andrew Salis 
Sarah Dermott 
Jerusha Murs 

Mary Sheridan 
Jane Loyd 
Ann Moor 


il 
11 


u 

li 
u 


a 


none 
feeble 

none 
none 
feeble 

feeble 

none 

feeble 


cal. gr. X every hour ; prep. c. 

acid, hydrocyan. 
prep, camph. 

cal. XX every 2 h.; prep, camph. 
cal. gr. x; prep, camph. 

acid, hydrocyan. injection 
cal. gr. X every h. " 


" 14 


Prison woman 


" 


u 


il 


feeble 


acid, hydrocy. injections 


" 15 

U il 


Cath. De Lacey 
Eliza Garley 


;; 


a 


u 

11 


none 
feeble 


cal. gr. X every h., inject's 
cal. gr. i, tr. opii, " 


11 11 
11 li 
li 11 

U 11 

il It 


Dominick Noon 

Alfred 

Marg. Barrucher 

Ann McDonald 

James Barry 

Charles Cowan 


;; 


a 
li 


11 


feeble 

none 

feeble 

feeble 

feeble 

feeble 


cal. gr. X every hour, inj. 
cal. gr. X " " " 
acid, hydrocyan. inj. 
cal. gr. X every hour, inj. 
cal. gr. X every hour, inj. 
cal. gr. X every hour, inj 


il li 


Pinkney 


" 


"■ 


slight 


feeble 


cal. gr. X every hour, inj 


il il 


Elizabeth Woolcott 


11 


li 


none 


feeble 


cal. gr. X every h., prep. quin. inj. 


11 11 


Mary A. Lentz 


'< 


'< 


'< 


none 


acid hydrocy. inj. 


a il 


Mary Ryan 


" 


" 


" 


none 


cal. gr. X every hour, inj. 


a li 


Fanny Driver 


il 


" 


" 


feeble 


acid, hydrocyan. inj. 


a 11 


John Hay 


a 


a 


a 


feeble 


cal. gr. X every hour, inj. 


<' 16 


Mrs. Morris 
Mrs. Atnully 


u 


u 


li 


feeble 
feeble 


cal. gr. X every hour, prep. cam. 
cal. gr. X every hour 


U li 


Shaughnessy 


il 


a 


" 


feeble 


cal. gr. X, inj. 


il il 


Mary Qumland 


il 


a 


" 


feeble 


cal. gr. X every h., inj. acid, 
hydrocyan. 


a a 


Henry Otten 


li 


a 


(( 


feeble 


cal. gr. X every hour. inj. 


11 11 


Selima Bernard 


u 


a 


a 


feeble 


cal. gr. X, opium gr. i, repeat 2ce 


11 a 


David Comstock 


il 


11 


a 


feeble 


cal. gr. X every hour, inj. 


a il 


Deborah Miller 


11 


li 


u 


none 


cal. gr. xevery h., inj., prep. cam. 


il li 


Jack, blk. 


a 


a 


il 


feeble 


cal. gr. X, followed by pulv. quod. 


a li 


Marg. 


a 


a 


" 


feeble 


mist, aromat. 


a Y 

a a 
il a 


Marg. Dutch 

Edward Florence 
Mrs. Smith 


li 


a 


li 
a 

1 


feeble 

feeble 
feeble 


cal. gr. X, cam. x, cap. x, mist. 

aromat. 
cal. gr. X, prep, camph. 
cal. XX, cap. x, cam. x, every 2 h. 



1850.] 



Reese's Notes of Hospital Practice. 



107 



Result 


Duration 


Previous 
sympt's 


Collapsed 


Remarks 


recovered 


24 hours 


unknowp 


not 




died 


3 days 


unknown 


in 2 hours 


Partial reaction ; relapsed. 


died 


6 days 


unknown 


partial 


Reacted, and died of secondary fever. 


died 


10 hours 


none 


deep in 6 hrs 




died 


12 hours 


none 


in 2 hours 




recovered 


24 hours 


none 


in 2 hours 




died 


23 hours 


none 


in 8 hours 




recovered 


5 days 


none 


in 6 hours 


Continued 12 hours; stomach irritable for se- 
veral days. 


recovered 


24 hours 


none 


not 


Ptyalised. 


recovered 


4 days 


none 


partial 


Vomiting ceased in few hours ; purging con- 
tinued 2 days. 


died 


5 days 


none 


partial 


Bilious vomiting and purging ; secondary fever. 


died 


9 hours 


unknown 


in 4 hours 




died 


14 hours 


none 


immediately 
immediately 


Slight reaction in 4 hours ; relapsed. 


died 


8 hours 


none 




died 


36 hours 


none 


in 4 hours 


Reaction in 8 hours ; relap,sed. 


died 


11 hours 


none 


immediately 


No reaction. 


died 


14 hours 


none 


immediatelj^ 


No reaction ; bilious vomiting from first. 


recovered 


3 days 


none 


partially 


Ptyalised ; bilious vomiting and purging. 


recovered 


3 days 


none 


partially 




died 


10 hours 


unknown 


immediately 


No reaction. 


died 


4 days 


unknown 


partially 


Reacted and died of secondary fever. 


recovered 


24 hours 


unknown 


not 




died 


17 hours 


unknown 


in 6 hours 


Diarrhoea 2 days. 


died 


15 hours 


unknown 


immediately 




recovered 


7 days 


unknown 


not 


Diarrhoea 24 hours ; secondary fever. 


died 


6 hours 


none 


immediately 




died 


7 hours 


none 


immediately 


No reaction. 


died 


3 days 


none 


partial 


Bilious vomiting; reaction; died of second'y 

fever. 
Reaction in 12 hours ; died of secondary fever. 


died 


7 days 


none 


partially 


died 


11 hours 


none 


immediately 


No reaction. 


died 


26 hours 


none 


in 10 hours 


No reaction. 


died 


24 hours 


none 


in 8 hours 


Diarrhoea 3 hours ; reaction and relapse. 


died 


13 hours 


unknown 


immediately 




died 


17 hours 


unknown 


in 3 hours 


Partial reaction. 


died 


12 hours 


unknown 


in 2 hours 


Diarrhoea 24 hours. 


died 


5 hours 


none 


immediately 




recovered 


3 days 


unknown 


partially 


Bilious purging. 


died 


5 days 


unknown 


partially 


Reacted, but died of prostration. 


died 


14 hours 


unknown 


in 6 hours 


Diarrhoea 24 hours. 


died 


22 hours 


unknown 


in 8 hours 




recovered 


6 days 


unknown 


not 


Diarrhoea 6 hours ; bilious vomiting and purg. 
ing 3 days. 


died 


13 hours 


unknown 


in 2 hours 


No reaction. 


died 


20 hours 


none 


immediately 


No reaction. 


died 


12 hours 


none 


immediately 


No reaction. 


died 


12 hours 


unlinown 


in 5 hours 


No reaction ; blue. 


recovered 


2 days 


unknown 


not 




died 


12 laours 


unknown 


in 4 hours 


No reaction ; 12 hours diarrhoea. 


died 


15 hours 


unknown 


in 5 hours 


Diarrhoea 24 hours. 


recovered 


24 hours 


unknown 


not 




died 


18 hours 


unlvnown 


in 3 hours 


Diarrhoea 24 hours. 


recovered 


3 days 


unknown 


in 4 hours 


Remained in collapse 14 hours ; no secondary 

fever. 
Diarrhoea 12 hours. 


recovered 


4 days 


unknown 


partially 


died 


30 hours 


unknown 


in 12 hours 


Diarrhoea 24 hours ; no reaction. 


died 


20 hours 


none 


immediately 


No reaction. 


recovered 


12 hours 


none 


not 


Diarrhoea for a day. 


recovered 


24 hours 


none 


not 


Diarrhoea for a day. 


recovered 


24 hours 


unknown 


not 




died 


30 hours 


unknown 


in 4 hours 


Diarrhoea 12 hours. 


died 


30 hours 


unknown 


in 6 hours 


Diarrhoea for a day ; refused to take medicine ; 

partial collapse. 



108 



Hartshorne's Notes of Hospital Oases. 



[Jan. 



Dates 


Name 


Purg- 
ing 


Vomit- 
ing 


Cramps 


Pulse 


Treatment 


July 17 


Leiper 

Prison female 
James Flanighan 


none 


none 


none 


feeble 
feeble 
feeble 


cal. XX, cap. x, cam. x, every 2 h. 


" 18 


Mrs. Barry 
Cath. Martin 

Sarah Hunter 




u 


u 
(< 


feeble 
feeble 

feeble 


cal. gr. XX, c. x, c. x, every 2 h., 
inj. 


" 19 


Mary McGuire 
Capt. Kearney 




" 


a 


feeble 
feeble 


" . " " " inj. 


" 21 


Wm. F. Todd 

Mrs. Ely 
McGlawn 
Mary Grayham 




- 


u 


feeble 
feeble 
feeble 
good 


" " <' " inj. 

a a a u 


" 22 


Smith, nurse 




a 


abdo'en 


feeble 


c. XX, cap. X, cam. x, every h. 


" 24 


Julia Laraby 
Cath. Kane 




a 


none 


feeble 
feeble 


u a u 11 
i( a li ci 


" 25 


Mary Taylor 




" 


u 


feeble 


u a a u 


" 26 


Eliza Crosby 
Jane 




u 


" 


teeble 
feeble 


a u li li 
11 li li li 


" 2 


Indian 




u 


a 


feeble 


cal. gr. X every h., prep. cam. 


" 26 


Big John 
Prison woman 




vomit'g 


u 

cramps 


feeble 
feeble 


cal. cam. capsic. " " 

a u a 



Art. IX. — Notes of Hospital Cases. By Henry Hartshorne, M.D.^ of 

Philadelphia. 



Aneurism of the Aorta. — The history of four fatal aneurisms, occurring 
in the Pennsylvania Hospital in 1846-7, is noted, with the post-mortem 
appearances. Three were abdominal ; one thoracic. The symptoms varied 
considerably; and in two of them the diagnosis was very obscure until a short 
time before death. 

The first, a Grerman, named Schrank, was remarkable for suffering under 
a general tendency to arterial dilatation and contortion. The subclavian and 
iliac arteries were all abnormally enlarged ; the heart was dilated and hyper- 
trophied, and two aneurisms of different size were found on the aorta. He 
remained in the wards for many weeks, dying at last from general irritation, 
without any rupture. 

In A n, who died the same day, pain and pulsation in the region of the 

liver, and diarrhoea, had been the prominent symptoms for several weeks 
before death. The autopsy displayed the tumour adherent to the liver, and 
proved that a rupture of the sac must have occurred four weeks at least before 
death, besides the one which destroyed him at last. ^^^J^ 

Michael Quigley, who had served in the Florida war, was the third. He 
was first admitted for bronchitis, 5th mo. 15th, 1846. A tumescence was 
then noticed over the arch of the aorta, in which strong pulsation was felt, 
and the sounds of the heart were heard with a ringing tone, on auscultation. 



1850.] 



Hartshome's Notes of Hospital Cases. 



109 



Result 


Duration 


Previous 


Collapsed 


Remarks 






sympt's 






recovered 


3 days 


unknown 


in 4 hours 


Diarrhoea for a day ; ptyalised. 


died 


30 hours 


unknovi^n 


in 12 hour^ 


Diarrhoea for 3 days. 


recovered 


3 days 


unknown 


in 4 hours 


Diarrhoea 12 hours; ptyalised. 


recovered 


3 days 


unknown 


partially 


Diarrhoea 2 days. ; 


recovered 


3 days 


unknown 


in 6 hours 


Diarrhoea 1 day ; ptyalised slightly. 


recovered 


3 days 


none 


in 2 hours 




died 


25 hours 


none 


in 8 hours 


No reaction. ' 


recovered 


2 days 


none 


partially 


Diarrhoea for a day. , 


died 


14 hours 


none 


in 3 hours 


Diarrhoea 12 hours. 


died 


18 hours 


unknown 


in 12 hours 


No reaction. i 


died 


18 hours 


unknown 


in 4 hours 


No reaction. 


recovered 


24 hours 


unknown 


not 


Diarrhoea 12 hours. 


recovered 


24 hours 


unknown 


not 


Diarrhoea 12 hours. 


died 


2 days 


unknown 


partially 


Reaction ; relapsed. 


died 


36 hours 


unknown 


in 12 hours 


Diarrhoea 6 hours ; blue col. 


died 


18 hours 


unknown 


in 8 hours 


Diarrhoea 24 hours. 


died 


12 hours 


unknown 


in 6 hours 


Diarrhoea 6 hours ; blue col. 


recovered 


12 hours 


unknown 


not 


Diarrhoea 7 hours. 


died 


36 hours 


unknown 


in 12 hours 




recovered 


24 hours 


none 


not 




recovered 


12 hours 


none 


not 


Diarrhoea 12 hours. 



Whole number of cases from June 10th to July 26th, 
a u recoveries " " " 

" " deaths " " " 

Rate of mortality — 67 per cent. 



137 
47 
90 



The existence of aneurism was, however, then doubted, from the absence of 
severe tracheal or (esophageal symptoms, and of thrill in the tumour. It was 
thought unlikely that the sternum should be much affected by a tumour 
which did not affect the thoracic tubes by pressure. A periosteal enlargement 
of the sternum was supposed to explain the case. His bronchitis being soon 
relieved, he was discharged. 

Qth mo. 24:th, however, he was again admitted, suffering with a hard^ 
hollow, tracheal cough, with paroxysms of threatened suffocation. 

9th mo. 12th. The tumour has very much enlarged, with characters leav- 
ing no doubt of its aneurismal nature. The symptoms continued the same, 
with emaciation and constitutional irritation. He died a few weeks later, and 
the diagnosis was verified by post-mortem examination. 

The last case was that of a man supposed, for a long time, to have lumbar 
rheumatism. Pain in the back and attenuation of frame, with loss of 
strength, were the only deviations from health. He was noticed, however, 
to find most ease in lying on his face, bent over the edge of a bed, with 
his feet on the floor. Dr. Pepper's scrutinizing examination detected, finally, 
a pulsation in the left hypochondriac region, with thrill, and bellows murmur, 
and some dulness on percussion. Corresponding with this posteriorly, near 
the spine, were found a decided prominence and strong pulsation, without 
thrill, as if the coagulum were there, and the channel anterior. Pressure 
No. XXXyn.— January, 1850. 8 



110 Hartshorne's Notes of Hospital Cases. [Jan. 

upon the nerves accounted for the pain, and obstruction of the thoracic duct 
was presumed to be the cause of emaciation. 

Dissection, after the fatal result, proved the immediate cause of death to 
have been rupture of the sac. The thor^ic duct was found to be forced con- 
siderably out from the spine, and much compressed, as had been anticipated. 

In the palliative treatment of these and other cases, the effects of digitalis 
were found to vary much with the individual. Three grains daily, in pill, 
reduced the pulse in four or five days in some, and acted diuretically. Others 
continued the same amount for weeks together, with no perceptible effect; 
and one had the pulse decidedly influenced only by taking eight grains 
daily. 

Abdominal Cancer. — Two remarkable tumours were examined with the 
knife, the previous history of one being almost unknown. The patient died 
on his way from the hospital gate to the building, before admission. The 
diseased formation was pronounced medullary cancer, and weighed about ten 
pounds. 

The other case was that of a man long in the wards, interesting chiefly 
from the obscurity of the exact diagnosis. It was impossible, during life, to 
ascertain the connections of the tumour; and in the autopsy it was entirely 
separable from each of the great viscera. Its origin was, therefore, by exclu- 
sion, ascribed to the mesentery. 

Fatal Hysteria. — A young woman, of previously dissipated character, 
an inmate of the house for a few weeks, died, in the summer of 1847, with 
symptoms resembling those of an ordinary hysterical paroxysm, no organic 
disease being discoverable. Partial paralysis of the lower limbs, with occa- 
sional pain in them, had been the most permanent disorder. Congestion or 
inflammation within the spinal sheath was inferred. 

Hysterical Convulsions. — A most violent case (that of Eliza J ), of 

several months' duration, produced surprise by complete recovery, after a 
variety of treatment had appeared to fail. Her paroxysms were exceedingly 
active and distressing, and recurred often six or seven times in the day, re- 
sembling very much in appearance the attacks of epilepsy. 

The protean character of hysteria was illustrated in Mary L , who 

suffered alternately with functional disorder of the stomach, with vomiting and 
hsematemesis; of the brain, with delirium; of the spine, with the ordinary 
convulsive affections; and, at different times, also, amaurosis, which was for a 
year complete in one eye, and was then transferred to the other. 

Fracture of the Skull. — The uncertainty of the trephine, as a means of 
cure, was demonstrated in the case of an unknown man, who died a few hours 
after admission. The fracture was in the base of the skull ; but the principal 



1850.] Hartshorne's Notes of Hospital Cases. Ill 

coagulum, whicli was of great size, was on the opposite side, and in the upper 
and middle portion of the cerebrum. 

Fracture of hotli Thighs. — An excellent cure was obtained by means of 
Physick's modification of Desault's apparatus. The experience of the hospi- 
tal continues to favour the use of this dressing for fracture of the thigh. The 
greatest care, however, will sometimes fail in preventing excoriation of the 
perineum or ankle ) and time may, perhaps, yet bring improvements. The 
points still unattained in the ordinary treatment of this fracture are : 1st, the 
use of the tuberosity of the ischium as the basis of counter-extension, as the 
least liable to excoriation; and, 2d, the distribution of the extending force 
over a surface sufficient to prevent undue pressure or friction. The latter in- 
dication has been several times successfully met by the application of broad 
adhesive straps spirally from the knee around the leg, tied together, and to 
the foot-board below the foot. Possibly, a modification of the fracture-bed 
may be constructed, making the bed itself the apparatus, and thus allowing 
counter-extending bands to be attached to both perinea, so as to require less 
stress on any one point. 

Compound Fracture of the Thigh. — Four cases of recovery, without amputa- 
tion, are recorded as having occurred in four years ', one gunshot, the others 
from falls or other violence. All were in young men of good constitution. 
The duration of the case was, in no instance, less than a year. 

Fractured Neck of the Femur, united. — The death from pneumonia of a 
man in the surgical ward, aged 73, enabled us to find the proof of complete 
union of the neck of the femur, fractured partly within and partly without 
the capsule. His age was the point of interest. 

Fractures of the AnMe. — Three interesting cases occurred, in which a cure 
was obtained after transverse fracture, in one with displacement of a fragment 
of the astragalus — without any serious inflammation of the joint, and with 
only partial anchylosis. The fracture-hox is employed almost exclusively in 
the Pennsylvania Hospital in treatment of fractures of both or either of the 
bones of the leg, or of those of the foot. Pupuytren's contrivance for frac- 
ture of the fibula has been abandoned as impracticable, or inferior to the box 
and pillow, with the addition, in some instances, of the bandage of Scultetus. 

Dislocation of the Elbow. — The statement of the uniform occurrence of frac- 
ture of the condyles with this luxation was contradicted in two well-marked 
cases, traced from the time of reduction, shortly after the accident, to that of 
restored action in the joint. 

Amputations. — During the winter of 1847-48, Dr. J. Randolph performed 



112 Hartsliorne's Notes of Hospital Cases. [Jan. 

the flap operation in a number of cases upon the leg and thigh. The termi- 
nation varied with the circumstances; but was certainly not below the average 
of amputations of the lower extremity. Dr. Randolph's preference was pro- 
nounced for the flap operation, both above and below the knee. He adopted 
the plan of Liston, of delaying the dressing of the stump for an hour after 
removing the limb, to ascertain whether reaction would produce hemorrhage 
from vessels untied. The irritation produced, however, by opening the stump 
even after that short time, when coagulation has begun to cause adhesions, is 
a reason why, unless hemorrhage does occur, the flap should not be disturbed 
on dressing. There is no doubt that this plan lessens the danger of extremely 
disadvantageous secondary hemorrhage afterwards. 

Injuries of the Right Leg. — Having noticed that this limb was more 
frequently the seat of accidents than the left in the wards, I made the com- 
parison accurately, at one time, of those in the house ; and found that of six- 
teen simple and compound fractures and amputations of the leg or thigh, 
thirteen were in the right, and but three in the left limb. If a hypothesis 
were allowed, possibly the fact might be explained on the idea that it is, in 
this country, chiefly from recklessness and overhaste that accidents occur ; the 
''best foot forward'' suficring the worst injury. 

Arrest of Hemorrhage hy Ma.tico. — The stump of an arm, amputated near 
the shoulder, bled secondarily to a dangerous amount, from the whole surface. 
Pressure having fiiiled, a paste was made' by moistening powdered matico, and 
this was spread over the part. It acted as an artificial coagulum, and checked 
the flow of blood, which did not afterwards return. The only other remedy 
would have been to tie the subclavian artery. 

Groictli of an Artery. — In the case of a young man named M'Yickars, 
whose legs were torn by red-hot wires, a hemorrhage of considerable amount 
occurred beneath the dressing, which was not disturbed for twenty-four hours. 
On removing the clot, there was found in it, continuous with the posterior 
tibial artery, a defined tubal coagulation or organization, soft and white, al- 
though even thicker than the arterial coats, which had progressed already to 
the length of a quarter of an inch or more. The closure of the end of a torn 
vessel, then, is not always the sole process which occurs. 

Union of sexmrated Flesh. — To add to the well-attested cases in which com- 
pletely excised parts have reunited with the body, I find, on my notes, that 
a coloured man, who had cut off" the whole pulp of the end of one forefinger 
with a razor, placed it on again, and came to the hospital. Finding the piece 
crooked, I pushed it, so that it fell off" into a basin of water. It was refitted, 
however, and left untouched for five days. It was then found to be entirely 
reunited, leaving a mere line to indicate the junction. 



1850,] Hartshorne's Notes of Hospital Gases. 113 

Denuded Bone. — Some beautiful instances of the power of the vis medica- 
trix were observed^ where bone had been, for a considerable space, deprived 
of its periosteum. The most interesting was in the stump of the leg of J. 
Sloan, amputated below the knee. Ulceration of the flap took place, leaving 
the point of the tibia projecting, quite bare, for at least one inch square. 
Granulations slowly covered it from the circumference, without the necrosis 
of any part, even superficially. 

Sloughing Ulcers. — No case of fatal hospital gangrene has occurred in the 
Pennsylvania Hospital wards during the last four years or more. The dis- 
ease, as an epidemic or endemic, is unknown there. Where a sloughing tend- 
ency was perceived, the applications which appeared to the writer of most 
service were the carrot poultice, and the wash of nitric acid, used daily, gtt. 
1. in Oj. 

Turner's Cerate.- — It being known that this preparation generally contains 
little or no carbonate of zinc, a specimen was received from Smith & Hodgson, 
druggists, of true cerat. zinc, carb., made with the pure carbonate, 5ij to the 
ounce of simple cerate. It appeared, on careful trial, to be superior, decidedly, 
to the old Turner's cerate in treatment of ulcers. 

Burns. — The most soothing and convenient first dressing for recent burns 
was found to be cotton dipped in sweet oil. The oil prevented the adhesion 
of the cotton to the cuticle, the removal of which often aggravates the case. 
Ice in bladders can be applied over the cotton, if desired. As a general rule, 
nothing surpassed the linimentum calcis in the after-treatment. 

^^ Inverted Toe-nail.''^ — The idea, now almost established, that the fleshy 
part of the toe, not the nail, is in fault in this affection, was confirmed in our 
cases. Four were entirely cured without any operation on the nail, by the 
introduction of lint covered with cerate, and the use of rest and emollient 
poultices, or water-dressing, aided perhaps by adhesive straps, to draw the 
nail from the inflamed part. 

One case presented very obstinate disease at the root of the nail itself, 
which was extracted three times without more than temporary benefit. 

Rupture of the Duct of Steno. — A boy was exhibited in whom this accident 
had taken place from a blow. No external fistula was formed, but a tumour, 
half as large as an egg, had accumulated from the effusion of saliva under the 
cheek. This was punctured by Dr. Pepper with a trochar. The tumour 
returned in a few days ; but the patient was lost sight of. 



114 Craghead's Oa%e of Double Pregnancy. [Jan. 



Art. X. — A Remarkahle Case of Double Pregnancy — one Ovum entering the 
Uterus, the other being arrested in the Tube. By Wm. Gr. Craghead^ M. D., 
of Danville, Virginia. (Communicated by Hugh L. Hodge, M. D., Pro- 
fessor of Midwifery in the University of Pennsylvania.) 

My dear Doctor : Tlie very interesting and unusual specimen of extra 
and intra-uterine pregnancy in the same individual, received from Dr. Crag- 
head, I submitted to my friend and assistant, Dr. John Neill, Demonstrator 
of Anatomy in the University, who has favoured me with an anatomical de- 
scription, now appended to this report. There can be no doubt whatever of 
the nature, as well as the singularity, of the case. The extra-uterine foetus, 
still attached by its cord to its own placenta in the tubal sac, its twin 
from the cavity of the uterus, and the still enlarged uterus, are all preserved 
by Dr. Neill, in my cabinet — the foetus developed in the abdominal sac 
being rather larger than its fellow from the uterine cavity. 

Respectfully yours, 
Dr. I. Hays. H. L. HODGE. 

Dec. 10th, 1849. 

Finding no record of the co-existence of a tubal and a uterine pregnancy, 
I think the following case will be an interesting item for publication, 

I was called, on the 9th of April last, to visit a negro woman, belonging to 
Mr. James Conway, of this neighbourhood. She was thirty-five years of age, 
of strong constitution, and had previously enjoyed excellent health. She had 
one child at an early age ; lived without a husband till she was near thirty, 
when she married, and shortly afterwards gave birth to her second child. 
Again she became "sine marito,^' in which state she remained until last 
Christmas. Having menstruated early in January, 1849, and not since, she 
supposed herself pregnant. About the first of April, she complained of pains 
resembling those of colic, in consequence of which, her master bled her, 
gave her an aperient, and occasionally a dose of laudanum to prevent abortion. 

I found her somewhat under the influence of laudanum, but feverish, and 
still complaining of considerable abdominal pain and soreness ; upon exami- 
nation, I discovered a tumour in the left iliac region, pressure upon which 
gave acute pain. This I pronounced at the time to be ovarian. I bled her, 
and gave calomel and opium, to be followed by oil and turpentine ; directed 
an antidynous liniment to be frequently applied during the continuance of 
pain and soreness ; and prescribed laudanum to prevent all uterine effort, and 
a mixture of spirits of nitre and balsam to relieve some symptoms of dysury. 

On the 12th, I visited her again. She was every way more comfortable, 
with but little fever or soreness, and had no dysury. I directed her to keep 
still, and to use aperients and laudanum, as either might be indicated. 

r 



1850.] Craghead's Case of Double Pregnancy. 115 

On the 17th, she felt so much relieved, that she spoke of walking out. As 
her bowels were constipated, she took a dose of mild cathartic pills at bed- 
time. Before day, she complained heavily, not, however, as if in labour ; but 
said " she felt as if there was something in her which ought to come away,'^ 
and made several ineffectual efforts to evacuate the bowels. 

On the morning of the 18th, I was hastily summoned to visit her, and 
told that she was in extremis. I found her in a collapsed state, with extremi- 
ties cool, and pulse scarcely, if at all, perceptible, sighing, tossing about, and 
complaining of a most distressing sensation in the lower part of the abdomen, 
which was now so greatly distended that I could not define the position of the 
tumour, which I had before noticed in the region of the left ovary. Her 
general appearance very much reminded me of the case of a lady, attended 
a few months before by Dr. Grreen and myself, who died of hemorrhage 
from an ovarian tumour. In the present case, in addition to the symptoms 
dependent upon internal hemorrhage, there were those of colic, and a con- 
stant, though vain, desire to evacuate the contents of the bowels and bladder. 
Opiates, internal stimulants, and counter-irritants to the extremities, were 
perseveringly used. The catheter was introduced, and the bladder emptied, 
affording a slight temporary alleviation of suffering. Her bowels were so 
constipated, that, notwithstanding the liberal use of calomel and croton oil, 
terebinthinate, and other enemata, during the three succeeding days that she 
lived, they were never evacuated. Her system, however, reacted about night. 
The next day, she was feverish, with considerable irritation of the stomach. 
Labour pains set in on the evening of the 19th, and in a short time she aborted 
without any diminution of the abdominal distension. The foetus was well 
formed, and of rather more than three months' development. She lived till 
the evening of the 21st, when she died rather suddenly; having presented the 
combined symptoms of obstruction of the bowels and loss of blood. 

April 22d. My partner. Dr. John J. Burton, assisted me in making a 
post-mortem examination. Upon opening the body, the whole abdominal 
cavity was found filled, anteriorly, with coagulated blood, and posteriorly with 
serum, which had proceeded from the rupture of some of the vessels of the 
left Fallopian tube, now greatly enlarged, and converted into a membranous 
sac, containing a foetus of the same size as the one delivered per vias natu- 
rales. The sac was removed entire ; and, intending to send the parts to you, 
the tubal foetus was preserved in its own liquor amnii three months, when, 
seeing no opportunity of forwarding it, the tube was opened in the presence 
of Drs. Atkinson, Green, Hoge, and Boan. The colon was enormously dis- 
tended with air, and in a state approaching gangrene. Whether the colic 
was primary, and hastened the ^^ unavoidable hemorrhage," or whether the 
obstruction of the colon was secondary, and dependent upon the pressure of 
the tumour, and the great quantity of coagula, I cannot say ; for we were so 
much interested by the discovery of the foetus, which, at this stage of the ex- 
amination, was seen through the transparent membrane in the Fallopian tube, 



116 Craghead's Case of Double Pregnancy. ^ [Jan. 

that the investigation in regard to the diseased condition of the bowel was 
prosecuted no farther ; and we gave ourselves up to reflection and speculation 
on this wonderful departure from the ordinary laws of nature. 

Dear Doctor : I have just completed a careful dissection and examina- 
tion of the specimen of double pregnancy sent to you from Virginia. 

The abnormal cavity is undoubtedly a dilatation of the Fallopian tube of the 
left side. I have exposed and traced the tube from the uterus to its infundi- 
buliform expansion into the walls of the cavity. I can find nothing like a 
continuation of the tube from the external side of the sac, nothing that can 
positively be considered as its fimbriated extremity. 

The distance between the uterus and the uterine side of the tubal cavity 
or sac, measured along the uncoiled and dissected Fallopian tube, is two and a 
half inches. 

The cavity itself is five and a half inches long, and three and a half inches 
wide, though it is much diminished and contracted from having been pre- 
served in alcohol. A more correct idea of its size would be given by referring 
to its contents. It contained a well-formed foetus, five and a half inches in 
kngth, with a cord and well-developed placenta attached. The ovary was 
readily dissected from the external surface of the sac, and its true fibrous struc- 
ture recognized. It is not much diminished in size, nor is there any altera- 
tion in its colour ; but its position is somewhat altered from the development 
of this new cavity. The ligament is much increased in size, and very fibrous 
in its appearance. 

The uterus now measures six and a half inches in length, and three inches 
in its greatest breadth, and contains a dark-coloured mass, which is probably 
a placenta. The foetus from this cavity measures but five inches. The Fallo- 
pian tube of the right side deviates from the usual appearance. It is very 
much dilated in its entire length, and its walls are much softer and less fibrous 
than in the natural condition of the tube. 

Yours, very truly, 
Prof. Hodge. JOHN NEILL. 

Dec. lOif/i, 1849. 



1850.] 117 



REVIEWS 



Art. XI. — A Treatise on Fractures in the Vicirdti/ of Joints^ and on Certain 
Forms of Accidental and Congenital Dislocations. By Robert William 
Smith^ M. D., M.R.I, a., Lecturer on Surgery at the Richmond Hospital 
School of Medicine^ &c, &c. Dublin^ 1847: 8vo. pp. 314. 

Nothing impresses the thoughtful student of medicine more profoundly 
than the apparent exhaustlessness of the subjects of his investigations. 
Enthusiasm and industry may have expended their energies upon a single 
department of the science; yet, compared with what remains to be known, 
they seem to him to have acquired nothing. He is constantly reminded of 
the beautiful ballad of Schiller, in which a spirit is represented as flying in 
quest of the last limit of creation. The adventurous voyager passed innume- 
rable worlds in his flight; but ever, as he wandered on, star after star continued 
to sparkle up before him. At last, wearied with his fruitless pursuit, and 
seeing the same infinity before as behind him, he returned, convinced that 
^^ Creation flows on to no shore. ^^ 

The subject of fractures and dislocations well illustrates this. Notwith- 
standing the many excellent treatises by the most celebrated professors of 
surgery, we have before us another volume which corrects many erroneous 
impressions, develops new facts and principles, and awakens inquiring thoughts 
on those very topics concerning which we fancied that we were best in- 
formed. 

The importance of the questions which the author investigates renders the 
reviewing of his labours a pleasing task. We shall follow his chapters in 
their own order. The first treats of ^'The diagnosis and pathology of frac- 
tures of the neck of the femur." 

Fracture of the neck of the femur is usually characterized by an array of 
symptoms and appearances which serve sufficiently to indicate the kind of 
injury which has been sufiered. They must be observed while the patient is 
in the recumbent posture, and also when he is standijig. In the former posi- 
tion, it will be found that the injured limb is shorter than the other, always 
measuring from the anterior superior spinous process of the ilium to the point 
of the internal malleolus; that the foot is everted; that the knee-joint is a 
little flexed; that the inguinal region is unusually full, while the upper and 
outer part of the thigh presents a degree of prominence, and a degree of 
tension, which are wanting in the other limb; that the trochanter major 
stands out in less bold relief than on the sound thigh, is approximated to the 
crest of the ilium, and revolves in the segment of a smaller circle than the 
other, when each limb is in turn rotated; that the contraction of the muscles 
about the hip can be overcome by steady and continued extension from the foot 
and leg, the shortened limb restored to its natural length, the foot inverted again, 
and a sound and feeling of crepitus produced by rotating the broken bone; 
but the unnatural appearances all recur when the extending force is with- 
drawn. The patient complains of pain in the thigh, particularly about the 
hip-joint; and this is aggravated by any attempt of the surgeon to rotate the 



118 Reviews. [Jan. 

foot inwards^ and to flex the thigli upon tlie pelvis; motions which the patient 
himself cannot accomplish at all^ or not without much labour and assistance, 
and suffering : while, on the other hand, he can increase the eversion of the 
foot, and extend the limb. All these signs are much increased in degree, if 
the patient is made to stand upon the uninjured leg, supported by an assistant. 
But, as Mr. Smith remarks, p. 5, ^Hhese symptoms are each liable to so many 
important varieties, and are so modified by the situation of the fracture, the 
relative position of the fragments, and the extent of injury done to the soft 
parts entering into the composition of the articulation, or in its immediate 
vicinity, that it becomes necessary to examine somewhat in detail the more 
important symptoms, and to consider attentively the circumstances which, in 
any given case, may modify the signs, and obscure the nature, of the injury 
which the hip-joint has suffered.^^ "The majority of the symptoms of fracture 
may be present in cases in which the neck of the femur is uninjured; and, 
on the other hand, the fracture may be unaccompanied by the more important 
of the usual diagnostic signs. We cannot, in investigating these injuries, form 
our opinion, guided by any -particular symptom; for there is not one which, 
separately considered, can be looked upon as unequivocally indicating the ex- 
istence of a fracture of the neck of the femur; it is by the union of all that 
we can alone hope to arrive at a correct diagnosis." 

The author, then, starting with this just conviction of the necessity of severe 
and unprejudiced examination of facts and statements, in the endeavour to 
arrive at the truth, proceeds to scrutinize the symptoms of fracture of the 
neck of the femur, and the effects of this injury, as described by others, and 
as observed by himself. 

The literature of this subject is sufficiently extensive. Among the French 
authorities, are Boyer, Desault, Dupuytren, Chassaignac, Cloquet, Cruveilhier, 
Rodet, Yidal de Cassis. Among the English, Sir A. Cooper, Earle, Stanley, 
King, CoUes, Adams, Amesbury, Lonsdale, Langstaff, Guthrie ; and not a few 
among the Glermans. In addition to a careful examination of such writers, 
Mr. Smith has diligently studied the appearances presented in one hundred 
and forty cases of fracture of the neck of the femur, sometimes during the 
life of each individual sufferer and after death, sometimes only after the 
patient^s death. And, in order that others may have the opportunity of com- 
paring his statements with the truth, he has succinctly narrated the histories 
of a great many cases, and has appended to each of them a beautifully exe- 
cuted drawing, exhibiting the situation of the fracture, and the subsequent 
changes which have occurred in the bone. Upon the facts thus gathered from 
many sources, Mr. Smith reasons fairly, closely, and, we think, conclusively. 
We shall endeavour to convey a just impression of his views. 

It would seem to require only an unprejudiced observation of cases of frac- 
ture of the cervix femoris, to determine whether there is the greater amount 
of shortening of the limb in the intra-capsular, or in the extra-capsular, va- 
riety of this injury. And yet, on this point, a very great difference of opinion 
exists on the part of high authorities. Sir Astley Cooper is probably regarded 
in England, and also in this country, as the most oracular judge of this ques- 
tion ; and his opinion is that, in the intra-capsular fracture, the shortening is 
from one to two inches {Treat, on Frac. and DisL, p. 113, Am. ed.) ; while 
in the fracture external to the capsule, " the injured leg is shorter than the 
other by one-half to three-fourths of an inch." ( Op. cit., p. 144.) In this 
statement, Amesbury, Chassaignac, Vidal, and some others, substantially agree 
with Cooper ; while, on the other hand, it is opposed by Stanley, Earle, Boyer, 
and others, who aver that the greater shortening occurred in the extra-capsular 



1850-] Smithes Treatise on Fractures and Dislocations. 119 

fracture. Rodet contends that this difference of opinion depends upon the 
fact that there is no constancy in the degree of shortening consequent upon 
these varieties of fracture. Our author dissents from this inference, and feels 
^'satisfied that the degree of shortening of the limb may, tcitJi certain pre- 
cautions, be considered as diagnostic of the seat of the fracture, and that it 
is greater when the lesion is external to than when it is within the capsular 
ligament,^^ p. 6 ; reference being had to the retraction which immediately suc- 
ceeds the occurrence of the injury. That Sir Astley Cooper intends the same 
limitation is manifest from his statement, that the shortening may, after a 
length of time, in consequence of gradual extension of the capsular ligament, 
amount to four inches. {Op. cit., p. 114.) In the treatise before us, Mr. 
Smith estimates the shortening which directly follows the fracture within the 
capsule at "from a quarter of an inch to one inch" — p. 110. An examina- 
tion of the statistical table of the cases of this variety of the injury, which is 
appended to his remarks, and a comparison of these with their published 
histories, support the above opinion. The number of cases of this injury, 
advanced at page 108, is twenty-eight, and in only ten of this number did 
the shortening exceed one inch ; of these, the retraction was one and a half 
inches in two cases, one and a quarter inches in four, two inches in three, and 
two inches and a half in one. Now, by referring to the notes of these cases 
at pp. 69-84, it will be found that in all of them cdjsorption of the neck of 
the bone had taken place, to a greater or less extent, sometimes entirely ; thus 
proving that the excess of the shortening beyond the degree mentioned as the 
extreme of immediate retraction was due to changes occurring subsequently to 
the receipt of the injury — changes which had been going on from "oTze montK' 
to "several years.^' — p. 108. 

The question very pertinently arises, how can this difference in the degree 
of retraction of the broken limb be accounted for, the kind of injury being 
the same in the different cases? "The chief circumstances,^' says Mr. Smith, 
p. 6, " according to which the degree of shortening varies in cases of intra- 
capsular fractures, are, the direction of the fracture and relative position of the 
fragments, and the amount of laceration suffered by the fibrous covering of the 
neck of the bone." The former condition applies to those instances in which 
the line of fracture is such that the drawing up of the lower fragment is pre- 
vented by the opposed surface of the upper fragment, there having been no 
displacement with regard to the diameters of the two portions. However, as 
the line of direction of the rupture of the fibres of the bone can only be dis- 
tinguished by a post-mortem examination, it is comparatively little interesting 
practically, excepting in so far as a knowledge of the possibility of such a 
condition should prevent the surgeon from deciding too hastily that no frac- 
ture exists, simply because there is little or no shortening of the limb. 
The other circumstance which has been considered as preventive of the usual 
amount of shortening, namely, the escape of the fibrous investment of the neck 
of the bone from laceration to any considerable extent, is one of more import- 
ance, bccjiuse it is more likely to arise than the former, and because its occur- 
rence may be more readily and more safely supposed ; and, moreover, if the 
before-mentioned happy obliquity in the line of fracture should take place, 
such a condition is more probable as a coincident event with that now under 
consideration. Concerning this firm envelope of the neck of the femur, the 
author thus remarks, p. 7 : " This important investment constitutes a cylin- 
drical sheath of great strength, extending from the inferior attachment of the 
capsular ligament to the circumference of the cartilage of the head of the 
femur; it is derived from the deep fibres of the capsule, and, here and there^ 



120 Reviews. [Jan. 

appears to be thrown into longitudinal folds or bands, wbich Weitbrecht has 
termed ^retinacula/ it is covered upon its external surface by synovial mem- 
brane, and numerous vessels pass along it to the head of the bone. It may, 
for convenience' sake, and from the function which it fulfils in many cases of 
fracture within the capsule, be termed the cervical ligament of ilte femurs 
If, as sometimes happens, the force which causes the rupture of the osseous 
fibres has exhausted itself in so doing, this so-called cervical ligament may 
remain intact, and will thus secure to the fragments of the bone two very im- 
portant conditions for the complete reparation of the injury; viz., perfect apposi- 
tion, and a medium for the transmission of nutritious matter, since blood-vessels 
ramify in this membrane previous to entering the bone, and '■'' the reserve power,'' 
as Mr. Paget happily expresses it, which dwells latent in every tissue, for pur- 
poses of self-preservation and reparation, will be exerted in the enlargement, 
and probably in the multiplication, of these vessels. It is not unlikely that, 
if a record of the condition of this fibrous investment of the neck of the 
femur, after the occurrence of the accident in question, had been kept, in all 
the instances published of bony union of the fragments, it would have been 
found to have escaped laceration, at least to a considerable extent ; and it will 
readily be conceived that this condition of the membrane may be associated 
with the favourable obliquity of the fracture before spoken of, in which the 
line runs from the inferior part of the base of the head obliquely upwards and 
outwards, thus furnishing a double cause for the continued apposition of the 
fragments. 

Instances of non-separation of the two portions of the broken neck of the 
femur, from one or both of the causes, are recorded by Sir B. Brodie (in 
Oooper, op. cit., p. 114), Stanley (^Med. Ghir. Trans., vol. xiii.), Cruveil- 
hier (^Anaf. Pathol. Livraison, xxvi.); these facts are cited by Mr. Smith. 
In addition to these. Dr. Mussey, the distinguished professor of surgery, in 
Cincinnati, has a specimen illustrative of the same condition. It is with great 
propriety, therefore, that Mr. Smith, as well as other wise surgeons, insists on 
the importance of not resorting to undue violence or diligence in the attempt 
to elicit crepitus in cases in which there is reason to apprehend the existence 
of fracture of the femur within the capsule of the hip-joint, and the expedi- 
ency of enjoining strict rest, and confinement in bed, for as great a length of 
time as if the crepitus had been heard and felt. The foUowiag case, reported 
by Mr. Stanley {^Med. Chir. Transact., vol. xiii.), is quoted by Mr. Smith, 
and its appositeness renders it worth repeating here. ^^ A man, aged 60, was 
knocked down in the street, and, on his admission into St. Bartholomew's 
Hospital, shortly after the accident, he complained of pain in the hip ; but 
there was neither shortening nor eversion of the limb, and its several motions 
could be executed with freedom and power. In this absence of ail the usual 
indications, a fracture was not suspected; the patient was, therefore, merely 
confined to his bed. At the end of a fortnight, he had an attack of inflam- 
mation in the intestines, from which he recovered, but sufiered a relapse, and 
died in the fifth week from the date of the accident. On examining the body, 
no trace of injury w^s found in the parts around the hip-joint; but, on open- 
ing the capsule, small efi"usions of blood, apparently not recent, were disco- 
vered beneath the synovial and fibrous membranes covering the neck of the 
femur, also beneath the synovial membrane covering the ligamentum teres. 
The head and neck of the bone were sawed through the middle, and in each 
portion a dark line, evidently occasioned by the effusion of blood, was seen 
extending through the bone at the basis of the neck. A fracture was disco- 
vered extending along this line ; but the broken surfaces were in contact, and 



1850.] Smith's Treatise on Fractures and Dislocations. 121 

the sjmovial and fibrous memhrane coveriDg the neck of the bone was unin- 
jured/' — p. 9. 

Another cause assigned by the author for the limitation of the shortening 
in intra-capsular fractures is the strong capsular ligament which embraces 
the joint so closely. In this opinion, the author, it must be remarked, is at 
variance with that of Sir A. Cooper and others, since, according to these 
gentlemen, the intra-capsular fracture is attended with more shortening than 
that which is external to the joint. But we think that his reasons for this 
belief are much more satisfactory than those urged in favour of the opposite 
view by its upholders In the first place, we have the positive testimony of 
facts, as adduced in the table at p. 109, by which it is seen that, (A fifteen 
cases of extra-capsular fracture, unaccompanied by impaction of the upper 
fragment into the cancellated structure of the lower, whereby the retraction 
of the latter would have been limited, all display a degree of shortening ex- 
ceeding one inch (which is the limit assigned by the author to the retraction 
of the lower fragment in the intra-capsida.r fracture, and which, we have seen, 
agrees with his tabular statement), varying from an inch and a quarter to two 
inches. Secondly, the probability is in favour of the same view. The capsu- 
lar ligament is rarely sufficiently lacerated to permit of the lower fragment 
escaping through the aperture ; and it therefore seems exceedingly improbable 
that the unruptured ligament, unless previously relaxed and lengthened by 
some chronic disease, as in the case mentioned by Mr. Langstaff ( Cooper, p. 
114), could permit of a degree of retraction of the lower fragment upwards 
at all commensurate with that produced in extra-capsular fractures by the 
power exerted upon it by the muscles which are inserted into it. 

Mr. Smith cites one of Sir A. Cooper's cases of extra-capsular fracture 
(Cooper, op. cit., p. 149, Case 93), in which the shortening did not amount 
to quite three-quarters of an inch; but in this case, as the author remarks, 
p. 11, Sir Astley has "entirely overlooked the influence which the circum- 
stance of the fracture having been impacted exerted upon the shortening of 
the limb," by preventing the full effect of muscular contraction. And, by 
referring to the other cases of this accident, recorded by Cooper [op. cit., p. 
145, et seq.), it will be found that in all of them in which he had the oppor- 
tunity of examining the bone after death, a similar impaction existed. On 
these grounds, therefore, we feel inclined to side with the author of the treatise 
under consideration, rather than with Cooper and his partisans. 

Mr. Smith believes " that all extra-capsular fractures are, in the first instance, 
also impacted fractures, and that all impacted fractures are necessarily accom- 
panied by a fracture traversing some part of the trochanteric region. ''' "I 
have," he says, " omitted no opportunity of investigating this point, and have 
now examined, here and elsewhere, upwards of one hundred specimens of the 
extra-capsular fracture, and have found in all, without a single exception, a 
second fracture traversing some portion of the inter-trochanteric space. This 
space is of a somewhat semilunar shape, bounded above by the summit of 
the trochanter major, below by that of the trochanter minor. Its concavity 
corresponds to the posterior inter-trochanteric ridge, and its convexity to a line 
drawn from the base of one trochanter to the other." ^"^The second fracture 
usually begins near the centre of the summit of the trochanter major, passes 
from thence downwards and inwards, generally following the convexity of the 
space I Jiave mentioned, and either terminates before it reaches the trochanter 
minor, or else it is continued through the centre or below the base of that 
process. Sometimes, it is a fissure, which splits either one or both trochanters, 
without detatching any portion of either. This second lesion of the bone is the 



122 Reviews [Jan. 

necessary result of the forcible impaction of the broken cervix into the shaft 
of the femur, and it is, probably, the second fracture in order of time. What 
occurs appears in fact to be this : the neck of the femur is, in the first in- 
stance, broken by the fall on the hip, and then driven into the cancellated 
tissue between the trochanter by the weight of the body and the prolonged 
action of the first shock. But, as soon as the neck of the bone is broken, the 
femur is rotated outwards, even before the action of the first impulse has 
ceased ; thus, the posterior inter-trochanteric ridge being thrown forwards is 
forcibly driven against the base of the neck of the femur. Two forces, there- 
fore, combine to produce the fracture through the inter-trochanteric space, 
one of which consists in the impaction of the cervix, into the shaft, while the 
other is found in the collision which takes place between the broken neck of 
the bone and the posterior inter-trochanteric ridge; and, moreover, this second 
fracture is as constantly present in cases attended with rotation of the foot 
inwards.''' — pp. 16-17. The degree of separation between the fragments thus 
produced must vary according to circumstances. The violence which caused 
the fracture may be so great as entirely to sever the trochanters from the shaft, 
and to set free the upper fragment from its nidus in the reticulated tissue 
between them, in which event there is nothing to prevent the effect of the 
contraction of the powerful muscles which pass from the pelvis to the shaft 
of the femur, and great shortening of the limb must result, as in the ordinary 
extra-capsular fracture. This complete severance and dislocation may be pre- 
vented by the cause of the fracture being less violent in its action, and by the 
escape from extensive laceration of the dense fibrous investment of the whole 
trochanteric region. We can even conceive, contrary to the opinion of the 
author, that, in consequence of a comparatively slight violence occasioning 
the fracture, there might be little derangement of the fragments in the diame- 
ter of the shaft, and consequently little or no rupture of the firm fibrous en- 
velope of the neck about the trochanters. In such a case, there would not 
necessarily be positive impaction of the neck in the cancellated structure, and 
the shortening would be proportionally small. And it is not unreasonable to 
think, that the senile atrophy and diminution in the powers of resistance of 
the osseous fibres would favour such a happy escape in those instances in which, 
as is sometimes the case, the injury occurs in elderly people; because in these 
a less degree of violence is required to break the bone. However, this fortu- 
nate category of suppositive coincidences rarely happens in actual life ; this 
is the exception, the other the general rule. 

Mr. Smith's remarks concerning the period at which shortening of the limb 
occurs, and the attendant circumstances, are very clear. There is considera- 
ble variety in both of these particulars. " It may manifest itself instantaneously 
upon the receipt of the injury, and that to a considerable degree. In such 
cases, the injury will generally be found to be a comminuted fracture external 
to the capsule, a fracture which has lacerated the whole of the fibrous struc- 
tures w^hich invest the trochanteric region of the femur." — p. 11. In other 
instances, the shortening of the limb is by no means decided or evident for 
several days, in consequence of the paralyzed condition of the muscles from 
contusion. Again, the primary retraction may have been slight, but, after 
the expiration of some weeks or months, the shortening has become consider- 
able, gradually, owing to the absorption of the neck of the bone. In Case 
No. 9 of the table of intra-capsular fractures, the shortening was at first only 
a quarter of an inch ; but, at the end of six weeks, it amounted to an inch 
and a half, from this cause. Other cases occur in which at first there is 
but trifling inequality in the length of the limbs ; but, at the end of an indefi- 
nite time, a considerable retraction of the broken thigh takes place suddenly y 



1850.] Smith's Treatise on Fractures and Dislocations. 123 

and synclironously with some unusually severe rotation or other motion of the 
limb. This last series of cases the author supposes to he instances of intra- 
capsular fracture, in which "the cervical ligament/^ as he terms it, had 
escaped laceration at the time of the injury, but, at this subsequent period, 
had been torn by some sudden movement, and had thus permitted the frag- 
ments to pass each other. — p. 12. This same immunity from primary 
shortening, with subsequent sudden retraction, may be attendant also upon 
those cases in which the line of the fracture was such that the lower frag- 
ment could not pass the upper until displacement had been occasioned by 
some violent motion of the limb. The interesting point is that, in the opin- 
ion of the author, "the sudden occurrence of shortening, at a period more or 
less remote from the receipt of the injury, is diagnostic of the existence of a 
fracture within the capsular ligament. ^^ 

The position of the foot, in fractures of the neck of the femur, receives 
due consideration from the author. — pp. 22-27. This is not a question of 
speculative interest merely. Probably the records of every large and long- 
established hospital, and the note-books of many old surgeons, will show that 
fracture of the neck of the femur has been more than once mistaken for dis- 
location of the head of the bone ; and, perhaps, many lives have been short- 
ened by excessive perseverance in endeavouring to reduce this imaginary injury. 
Such an error of diagnosis is very likely to result from the inversion of the 
foot, which sometimes accompanies fracture of the cervix femoris; and the 
danger of such a mistake is increased when a portion of the trochanter major 
is detached, and drawn upwards, so as to simulate the head of the thigh bone. 
Many explanations have been offered to account for this unusual direction of 
the foot, but as yet none has been devised which will apply to all cases. The 
weight of the limb and the powerful influence of the rotator muscles outwards 
sufficiently elucidate the eversion of the foot j but any position may be assumed 
between this extreme and its opposite, inversion, both in the intra-capsular and 
extra-capsular fracture, but more frequently in the latter variety — in five cases 
of seven which the author has examined. It may remain undeviated from its 
natural direction when, in consequence of the circumstances before mentioned, 
there has been little or no displacement of the broken surfaces as regards 
their diameter; or when, as in the case quoted from Mr. Amesbury, at p. 25, 
the fibres of the firm investment of the neck have been preserved unruptured 
on its anterior face ] it may be inverted when, as Mr. Guthrie suggests, the 
line of fracture is such that the powerful muscles, which rotate the thigh out- 
wards, can no longer act upon the lower fragment. But these explanations 
apply only to individual cases. The author says that, in every case of fracture 
of the neck of the femur which he has had the opportunity of examining after 
death, and in which there was inversion of the foot, the inferior has been placed 
in front of the superior fragment ; and he suggests that, in these cases, the 
inversion of the foot may have been due to the fact that, in consequence of 
this position of the lower fragment, the direction of the fibres of the outer 
rotator muscles may have been so changed as to render them rotators inwards. 
He admits, however, that this explanation will scarcely apply to inversion 
of the lower fragment in intra-capsular fractures, "for, in such cases, it is 
difficult to conceive how the lower fragment could be thrown so far forwards 
as to affect the action of the muscles, by altering the direction of their fibres. ^^ 
This suggestion, which attributes more influence to the position of the bones, 
primarily, than to the muscles, receives confirmation from an observation 
which is original with the author; namely, in some instances of fracture of the 
neck of the femur, accompanied by inversion, when the shortening had been 



124 Reviews. [Jan. 

removed by extension, and the direction of the foot rectified, so soon as the 
extending force had ceased to act, the shortening recurred, but the foot became 
everted"; and he justly urges, with Oruveilhier, that, if muscular agency caused 
the inversion in the first instance, the same result should always follow its 
exercise. — p. 25. 

With respect to the means of distinguishing between the intra-capsular and 
the extra-capsular fracture, the author insists upon the necessity of careful 
examination of all the symptoms. The most reliable points may be thus 
summed up : — 

1. The extra-capsular non-impacted fracture may generally be recognized by 
the existence of an amount of shortening varying from one inch to two and a 
half inches ; by eversion of the foot ; by the comparative ease with which the 
limb may be restored to its natural length, when, by rotation, crepitus can be 
elicited, with the recurrence of shortening, accompanied sometimes by ever- 
sion of the foot, if the latter had been at first inverted; by the often great 
degree of pain about the hip, and the ecchymosis, visible externally, being 
more marked than in the intra-capsular fracture ; by the very complete loss of 
power of the limb. 

2. The extra-capsular impacted fracture is usually indicated by ^^ slight 
shortening of the limb ; slight eversion of the foot ; absence of crepitus ; great 
difficulty in all cases, and in the majority of instances an impossibility, of re- 
moving the shortening of the limb by extension ; and by less loss of power 
than in other forms of fracture of the neck of the femur.'^ — p. 32. In addition 
to these circumstances, subsidiary means of diagnosis exist in the conditions 
insisted upon by Cooper, particularly ; namely, that the fractures external to 
the capsule are generally occasioned by a severe injury, and occur at a less 
advanced a.ge than those within the joint. Moreover, the existence or absence 
of the symptoms indicative of chronic disease of the hip-joint should be 
ascertained in order to guard against error from this source. 

3. The intra-capsidar fracture may be distinguished by the immediate 
shortening being only from a quarter of an inch to one inch, and by this re- 
traction being easily overcome by extension; by the facility with which crepitus 
may be produced ; by the loss of power being generally complete ; by the rarity 
of inversion of the foot, as compared with this position in the extra-capsular 
impacted fracture ; by the age of the patient being beyond fifty years, and by 
the often slight violence which has occasioned the injury; finally, if sudden 
occurrence of shortening, or sudden increase of the shortening, be observed, 
at a period more or less remote from the date of the accident, the injury is, 
in all probability, a fracture within the capsule. 

The anatomical characters of the two varieties of this fracture are detailed 
at considerable length, and very carefully. — pp. 32-68. We have not space 
sufficient to permit of a full transfer of the observations on these points. We 
can only notice briefly the most important. 

The author has met with one specimen of extra-capsular fracture in which 
the lower fragment had penetrated a short distance into the cancellated tissue 
of the superior, the reverse of the general condition. Another example of the 
same kind is adduced by Mr. King, in the Cyclopedia of Surgery. 

He has also studied the nature and uses of the exostotic growths which are 
often found after fractures external to the capsule, being deposited chiefly 
about the trochanters, and the lines which connect them. The usual opinion 
entertained of these excrescences is that they are produced for the purpose of 
affording a nidus, a species of socket, into which the neck of the bone may be 
received after the severance of its natural connections ; or with the view of 



1850.] Smitli's Treatise on Fractures and Dishcatwns. 125 

supporti^jg the acetabulum when the weight of the body is borne by the in- 
jured limb. The author dissents from this very mechanical notion ; '^ the final 
cause of their formation is the union of the fracture already described as tra- 
versing the inter-trochanteric space, and the constant existence of which, in 
cases of extra-capsular impacted fractures, has been overlooked by the gene- 
rality of writers. ^^ — p. 40, If it be asked, why is bony matter deposited most 
abundantly here ? the answer may, perhaps, be found by consideration of 
the interesting fact mentioned by Mr. Paget (^Lect. on Nutrition, London 3Ied. 
Gaz., vol. V. p. 97), that excessive reparative growth in bone is always found 
most luxuriant about the original centres of ossification. Now, in the femur, 
the original points of ossification are, for the upper part of the bone, one at 
its head, and one for each trochanter. ( Quain and Sliarpei/.') 

After intra-capsular fractures, the post-mortem appearances are very various. 
We have nowhere seen them so amply narrated as in this treatise. We can- 
not, however, detail them ; and the mere mention of them would not be at all 
satisfactory to a zealous inquirer. We must consequently refer such to the 
pages of the book itself 

We must mention, notwithstanding, that the author does not admit, so far 
as reason and experience allow him to judge, the existence of partial fracture 
of the cervix femoris, as described by Mr. Colles and Mr. Adams ; but con- 
siders that the cases on which the conclusions of these gentlemen are based 
are instances of complete and impacted fracture.- — pp. 44-52. 

Touching the question of bony reparation in intra-capsular fracture, Mr. 
Smith adds his assent to the affirmative, and quotes several cases in support 
thereof. His remarks in this connection are full of interest. Alluding to 
the opinions of Mr. Bransby Cooper and Cruveilhier, who contend, the former 
"that it is ordained by nature, that fracture of the neck of the femur, within 
the capsular ligament, is not to unite by ossific deposition,^^ and the latter 
" that bony union is here impossible, in consequence of the fragments not 
being surrounded by tissues capable of forming callus,^^ the author says, p. 
53, '■^ Now I believe that both the authors just alluded to are in error, in sup- 
posing that the efi"usion of callus around the fragments is necessary for the union 
of this fracture ] and must altogether dissent from the opinion which main- 
tains that the ends of the broken bone take no part in accomplishing osseous 
union. How is union accomplished in extra-capmlar impacted fracture ? 
Surely it must be by the direct union of the two bony surfiices which are con- 
fronted to each other. The surrounding soft parts cannot be in any way con- 
cerned in the process; the osseous matter which we find eifused along the 
posterior inter-trochanteric space being intended for the union, not of the 
broken cervix, but of the fracture through the trochanter, as has been already 
explained; and I believe that, whenever reparation by bone occurs in the 
intra-capsular fracture, it is owing to the direct union of the broken surfaces; 
and that the eifusion of callus around the fragment is by no means essential 
to the process.'' In support of this opinion, which seems very reasonable 
and probable, he refers to the published cases of bony union of this fracture, 
all of which have been examples, he says, of one or other form of impacted 
fracture : either the lower fragment has penetrated the cancellated tissue of the 
head of the bone, or else the broken surfaces presented corresponding depressions 
and prominences which mutually accommodated each other, so that the frag- 
ments were as if dovetailed into each other, and thus kept in contact. And 
he adduces, in further confirmation of this view, the fact that, in fracture of the 
cranial bones, and of the patella, longitudinally, reparation takes place with- 
out the effusion of callus, by the direct union of the opposing surfaces. 
No. XXXVII.— January, 1850. 9 



126 Reviews. [Jan. 

The author concludes his remarks on the subject of fracture of Jfie neck 
of the femur by a sententious summing up of the results of his studies : — 

The second chapter of the volume gives an exceedingly instructive history 
of ^^ chronic rheumatic arthritis of the hip-joint/' its symptoms, and the 
anatomical lesions which characterize it. The post-mortem appearances are 
beautifully delineated, so as to illustrate the text, and to explain the pheno- 
mena witnessed during life, and the sources of error in diagnosis. 

We pass to the third chapter, which considers "Fractures of the bones of 
the forearm, in the vicinity of the wrist-joint.^^ — pp. 129-175. Of these acci- 
dents, by far the most common is the fracture of the lower extremity of the 
radius, accompanied by more or less displacement of the lower fragment 
backwards. Mr. Colles, before whose time this injury was generally considered 
as a dislocation of the lower extremity of the radius, called Desault's, from 
the distinguished French surgeon, who first pointed out its true character. His 
paper on the subject was published in the tenth vol. of the Edinburgh Med. 
and Surg. Journal^ 1814; and the author of the treatise before us very justly 
complains that, for more than thirty years, subsequent writers have described 
" Colles' fracture,^^ without alluding to the name and opinion of this gentle- 
man in connection with it. 

Mr. Smith's account of the pathology of this accident is the most complete 
and carefully drawn up of any that we have seen. It is scarcely needful for 
us to enumerate the symptoms as given by him, because these are generally 
familiar to surgeons. We shall repeat, as concisely as possible, his account 
of the post-mortem revelations, and these will sufficiently involve the appear- 
ances presented during life. 

" The most usual seat of the fracture is from three-fourths of an inch to 
one inch above the radio-carpal articulation; sometimes it is only a quarter of 
an inch above the joint, but I have never seen it higher than one inch. It 
always appears to be higher than it really is ; but, should the lesion take 
place at two inches, or two and a half inches, above the radio-carpal articula- 
tion, the injury no longer presents the peculiar and remarkable characters 
which distinguish Colles' fracture of the radius." — p. 137. 

" The fracture is usually found to be transverse, even in cases where the ex- 
ternal character of the injury would lead us to suppose that the bone had 
been broken very obliquely ; this apparent obliquity is, however, the result 
of the mode of displacement of the lower fragment, which is drawn obliquely 
backwards in such a manner that the carpal surface of the radius, instead of 
having its normal direction downwards, forwards, and inwards, now looks up- 
wards, backwards, and outwards, its anterior descending below its posterior 
margin, and the styloid process iDeing raised and drawn backwards towards 
the side of supination. This twofold displacement is the result of the action 
of the supinator longus on the one part, and of the long extensors of the 
thumb upon the other ; the latter, as soon as the resistance of the carpus is 
removed by the occurrence of the fracture, draw the lower fragment of the 
radius, with the carpus, towards the side of extension, thus directing the 
articulating surface of the radius upwards and backwards, while the supinator 
longus, besides supinating the lower fragment, also elevates the styloid process, 
giving the carpal surface an inclination outwards.'^ "So long as the inferior 
radio-ulnar ligaments remain unbroken, and the lower end of the ulna is entire 
(which conditions are required by the particular fracture in question), it is 
obvious that the inferior fragment of the radius must be displaced obliquely^ 
that, in fact, the styloid process (when being drawn upwards and backwards), 
must move through a portion of the. circumference of a circle, and thus the 



1850.] Smithes Treatise on Fractures and Dislocations. 127 

upper end of the lower fragment is thrown towards the ulna. The pronator 
quadratus acts nearly altogether upon the superior fragment, for at least two- 
thirds of it are above the line of the fracture^ and in some instances the solu- 
tion of continuity of the bone is close to the inferior edge of this muscle. 

^^The displacement of the lower fragment 'backwards is very seldom carried 
to such an extent as to enable it to clear the inferior surface of the upper 
fragment." 

With regard to the direction of the fracture, he says, " I have lately ex- 
amined more than twenty specimens of the injury, and have not found one in 
which the bone had been broken with any considerable obliquity from above, 
either downwards and backwards, or downwards and forwards ; in all of them, 
the anterior and posterior margins of the fractured surface have been nearly 
upon the same level, and the surface has been plane. There is, however, an 
obliquity which the fracture not unfrequently presents, and which is directed 
either from within downwards or outwards, or from without downwards and 
inwards; even this obliquity is always trifling.'' — p. 142. 

It will be perceived that the author considers the line of fracture to be 
transverse, and that the lower fragment seldom passes the inferior surface of the 
upper, the ligaments being unruptured, and the ulna unbroken : how, then, does 
he account for the shortening of the radius, which almost always accompanies 
this injury? He says, page 138 : ''I admit that there is generally shorten- 
ing of the radius, even in cases where the fracture is directly transverse ; but 
in consequence of the peculiar mode of displacement of the lower fragment — 
a displacement which directs the carpal surface of the bone backwards instead 
of forwards, a displacement in which the carpal surface undergoes ^ a mouve- 
ment de bascule' — the shortening is confined to the posterior surface of the 
bone; the anterior, so far from being shortened, sometimes measures even 
more than it did previous to the accident, although, certainly, it must be con- 
fessed that, to detect this increase, the utmost possible nicety of measurement 
is requisite." He refers also to the well-known anatomical fact that the pos- 
terior surface of the radius is longer than the anterior ; in one specimen, which 
be alludes to, the latter was a quarter of an inch shorter than the former. Of 
two specimens of the fracture, which he cites, the posterior surfaces of the 
bone, in one, measured eight inches, and the anterior eight and a half inches; 
in the other, the surfaces are each eight inches long. In a tabular statement 
which is introduced in the course of his remarks, p. 156, this same difference 
of length in favour of the anterior over the posterior surface of the bone, in 
cases of the fracture under consideration, is observable. The table is based 
upon an examination of twenty cases, and three more are enumerated in the 
appendix. In one of these, the fracture was " nearly transverse;" in another, 
^^ oblique downwards and inwards;" in the remaining twenty-one, it was 
" transverse." In four of these cases, the length of the two surfaces was the 
same ; in eiglity the anterior exceeded the posterior in length by half an inch ; 
in ten^ by quarter of an inch ; and in one by three-fourths of an inch : those 
two in which the fracture was more or less oblique offered an excess of half an 
inch in favour of the anterior surface. 

The author combats successfully, we think, the opinion of M. Yoillemier 
(^Arcliivcs Gen. de 3Ied., IMars, 1842), which supposes that all fractures of the 
radius, within an inch of its carpal surface, are instances of impacted fracture. 
The grounds upon which M. Voillemier urges this view are that, by the force 
which occasions the fracture, the upper fragment is driven into the cancellated 
structure of the lower, and that, "in' all the specimens of fracture of the lower 
end of the radius, examined long after the accident which broke the bone, a 



128 Reviews. [Jan. 

line of compact tissue is found^ covered over with cancellated structure, directed 
vertically, and descending to within a greater or less distance of the articular 
surface of the radius. This line is never double ; it is continuous with the 
posterior wall of the bone when the lower fragment is thrown backwards, and 
with the anterior when this fragment is displaced forwards/' — p. 144. Mr. 
Smith admits the accuracy of these statements of facts, but dissents from the 
inferences which M. Yoillemier draws from them, on the grounds that no 
evidence drawn from recent fractures countenances the opinion, and that 
the theory demands a greater degree of shortening of the bone than is met 
with in Colles' fracture. He, therefore, thinks " that the impaction is only 
apparent, and that the compact tissue of the shaft is not found enveloped 
in bone, from its having penetrated the lower fragment at the time of the 
occurrence of the injury, but because it becomes subsequently encased in 
osseous matter during the process by which the bony union of the fracture is 
accomplished. '^ 

The remaining pages of this chapter are devoted to the description of the 
"fracture of the lower end of the radius, with displacement of the lower frag- 
ment forwards," and the " separation of the inferior epiphysis of the radius, 
with fracture of the lower extremity of the ulna." We shall not further 
allude to these. 

There is one variety of fracture of the radius to which Mr. Smith does not 
refer. We mean that which was described by Dr. J. R. Barton, of this city, 
and of which the original account is contained in the Phila. Med. Examiner, 
vol. i. 1838. In this injury, "a fragment is broken off from the margin of the 
articular surface of the radius, carried up before the carpal bones, and rested 
upon the dorsal surface of the radius." " The fragment may be, and usually 
is, quite small, and is broken from the end of the radius on the dorsal side, 
and through the cartilaginous face of it, and necessarily into the joint. The 
pronator quadratus is not involved in the fracture. The radius and ulna are 
not materially disturbed in their relations to each other. The only important 
change which takes place in consequence of this fracture is, that the concave 
surface at the extremity of the radius, which receives and articulates with the 
first three carpal bones, is converted, as it were, into an oblique surface by the 
loss of a portion of its marginal ridge; commonly by the separation of an 
entire piece; sometimes by the crushing of its substance, &c." {Op. cit.,'p. 
366-7.) 

The term " Barton's fracture" is commonly employed in this city, and, 
perhaps, in many parts of this country, as a sort of patrom/mic for all frac- 
tures of the lower end of the radius, very near the joint. This is a mistake. 
The paper of Dr. Barton makes no mention of any post-mortem evidence in 
favour of the reality of the lesion which he describes ; but he styles it " a sub- 
luxation of the wrist, consequent to a fracture through the articular surface of 
the carpal extremity of the radius." Sometimes, though rarely, the line of 
fracture is from i\iQ palmar surface of the radius upwards into the joint, with 
displacement of the lower fragment upwards on the anterior aspect of the 
arm. 

In chapter fourth, the author considers the subject of fractures of the 
humerus, in the vicinity of the shoulder-joint. — pp. 176-208. 

The first of these injuries which he describes is that in which the solution 
of continuity has taken place through the upper part of the bicipital groove, 
thus detaching the greater tubercle of the head of the humerus. The injury 
is caused by a fall or severe blow upon the point of the shoulder, and the 
symptoms are such as to simulate a dislocation of the head of the bone ; a 



I860.] Smith's Treatise on Fractures and Dislocations. 129 

tumour may be felt near tlie point ; the acromion process of the scapula is 
unusually prominent ; the breadth of the articulation is greater than that of the 
opposite joint; the elbow is somewhat raised from the side, and the power of 
the muscles over the arm and shoulder is impaired; sometimes, moreover, no 
crepitus can be detected. The diagnosis may be established by noting that, 
although the acromion is prominent, it is less so than when the head of the 
bone is removed from the glenoid cavity, nor can the finger be thrust beneath 
the process, as in dislocation ; that the arm can be readily pressed to the 
side, if it is parted from the latter; that the motions are rarely so much im- 
paired as in the luxation ; that the most superficial tumour hardly corresponds 
in size and shape with the head of the humerus, that it is separated from an- 
other tumour on its inner side by a sulcus, and that this second prominence 
agrees in situation with the glenoid cavity, follows every motion impressed 
upon the arm, and, in short, is evidently the head of the humerus lying in 
its natural resting-place. The treatment of this injury consists in keeping 
the arm at rest, the elbow being supported, and in restoring the fragment to 
its normal position by means of a compress and bandage. 

The next described form of injury is the imfpacted fracture of the neck of 
the humerus. The author says, p. 184 : ^' The neck of the humerus is not 
unfrequently the seat of a fracture analogous, in many respects, to the im- 
pacted fracture of the cervix femoris. Of this form of injury I have seen 
two varieties, in one of which the upper extremity of the lower fragment, or 
a portion of it, penetrates the reticular tissue of the head of the bone; this 
is an extra-capsular fracture, and occupies the situation which, in the young 
subject, marks the junction of the epiphysis with the shaft; in the other, the 
superior fragment is forced downwards into the cancellated structure between 
the tubercles, the greater of which processes is, in almost every such instance, 
split off from the shaft of the humerus ; in this case, the fracture is intra- 
capsular, and occurs through the anatomical neck of the bone.^^ Again : ^' The 
diagnostic signs of fracture of the neck of the humerus, accompanied by 
-< penetration of the superior by the inferior fragment, are remarkably obscure, 
and the true nature of the injury is exceedingly liable to escape detection; 
there is but little deviation from the natural form of the shoulder, nor is there 
any appreciable alteration in the length of the limb. When the surgeon 
places one hand upon the shoulder, and with the other rotates the elbow, the 
head of the bone will be felt moving with the shaft ; no satisfactory informa- 
tion is acquired by examining through the axilla, for although, perhaps, a 
slight irregularity may be felt near the junction of the neck with the head of 
the bone, it is usually so inconsiderable that it cannot be looked upon as 
affording positive evidence of the existence of a fracture in this situation." 
But there is a slight alteration of the natural contour of the shoulder, the 
motions of the arm are impaired, there are no sutficient evidences of luxation 
of the head of the bone, nor of fracture of the neck of the humerus, of the 
ordinary kind, and the injury has been occasioned by a violence inflicted upon 
the upper and outer part of the shoulder. The question may be decided by 
the development of crepitus, in the following manner : '•'' Let the surgeon with 
both hands firmly grasp the head of the bone, and maintain it as nearly as 
possible in a fixed position, while an assistant rotates the elbow ; by this method, 
crepitus can be produced in the great majority of cases." — p. 186. A drawing 
is appended, showing the appearances presented in such extra-capsular impacted 
fractures of the neck of the humerus. 

"In the second form of this remarkable injury, the fracture is situated 
higher up, and traverses the anatomical neck of the bone, tcithin the inferior 



130 Reviews. [Jan. 

attachment or base of the capsular ligament. It is a true intra-capsular 
fracture of the neck of the humerus, in which the head of the bone, or su- 
perior and smaller fragment, is driven into the inferior, or larger, between the 
tubercles, one or other of which processes is usually broken off from the 
shaft/' 

^'The arm is slightly shortened, the acromion process projects more than 
natural, and the shoulder has lost, to a certain extent, its rounded form; the 
upper extremity of the shaft of the humerus is approximated to the acromion, 
and the entire of the globular head of the bone cannot be felt. In conse- 
quence of the fracture of the tuberosity, crepitus can be readily detected, 
when the shoulder is grasped with moderate firmness, and the arm rotated. 
The absence of a rounded tumour in the axilla, and the impossibility of feel- 
ing the glenoid cavity, are sufficient to enable us to distinguish this injury 
from luxation. With the ordinary fracture of the surgical neck of the 
humerus it would be scarcely possible to confound it, for in this injury the 
elbow is separated from the side, an evident depression exists two or three 
inches below the acromion process of the scapula, the upper end of the lower 
fragment projects towards the axilla, and the axis of the arm becomes oblique 
from above and within, downwards and outwards." We cannot glean from 
the text any diagnostic of this between the intra and exira-capsular impacted 
fractures excepting this, that in the former it is generally easier to elicit crepitus, 
in consequence of the detachment of one or both of the tuberosities, which 
complication more frequently attends the former than the latter. 

There is no doubt that both of these varieties may be repaired by bony 
union of the fragments. Indeed, if the head of the humerus be severed by 
violence from its anatomical neck, even if there be no impaction, bony repa- 
ration may still take place, but probably in those cases only in which the 
capsular ligament has been more or less preserved. The circumstance of im- 
paction increases the probability of this mode of union, because it enables 
the lower fragment to take a direct part in the work of depositing a blastema 
in which ossification may go on between the fragments. "The reparation of 
the injury," says the author, "is accomplished principally by the lower frag- 
ment, which throws out bony matter in great profusion, and frequently gives 
rise to irregular stalactiform productions, which encase, as it were, the superior 
fragment." — p. 190. 

The following lines convey a most judicious and necessary caution. "The 
impacted fracture of the neck of the humerus always unites with a certain 
amount of deformity, which, indeed, from the very nature of the lesion, it is 
impossible to obviate; and, as regards the intra-capsular variety, it would be 
imprudent to restore to the joint its natural form, even were it in our power 
to accomplish it, for we would thus materially diminish the chance of the 
occurrence of osseous consolidation. It is, therefore, sufficient, in the treat- 
ment of such cases, to bandage the arm to the side, and to support the fore- 
arm in a sling; but the prudent surgeon will never omit to announce to the 
patient that a certain degree of impairment of the motions of the joint will 
be a permanent result of the injury." 

A very remarkable peculiarity sometimes met with in cases of these im- 
pacted fractures is, that the head of the bone, or the upper fragment, is more 
or less completely turned in situation, so that its cartilaginous surface looks 
downwards, in a measure. Yet, notwithstanding this unfortunate position, 
strange to say, bony union has been known to occur between the fragments. 
Interesting examples and drawings illustrative of these various conditions are 



1850.] Smith's Treatise on Fractures and Dislocations. 131 

given in the author's pages, the results of his own observations and of those of 
others. 

This chapter concludes with some observations concerning the "separation 
of the superior epiphysis from the shaft of the humerus/' The chief and 
most interesting facts, or rather remarks, which we find, are the clearness of 
statement as to the anatomical situation of the epiphysis, and the correction 
of the mistakes of Sir Astley Cooper and Yidal (de Cassis) on this point. The 
author calls attention to the fact that, in separation of the epiphysis from the 
shaft, the line of severance falls helow the tuberosities, so that the processes 
will form part of the upper fragment. There is rarely a failure in the repa- 
ration of this fracture by bony union, because the surfaces are so broad, and 
the fracture so transverse, that the fragments can scarcely be entirely separated 
from each other, excepting from extraordinary violence ; and, again, because 
an abundant nutrition can be maintained from the superior, as well as from 
the inferior, fragment. — pp. 199-206. 

The fifth chapter is devoted to the examination of "fractures of the acromial 
extremity of the clavicle." 

According to most authorities, but very little, if any, displacement results 
from fracture of the clavicle, exterior to the coracoid process and to the 
coraco-clavicular ligaments. The internal fragment is, agreeably to these 
gentlemen, prevented from changing its line of direction, and maintained in 
its true position, by the conoid and trapezoid ligaments, and the outer is like- 
wise held m sit'd by the acromio-clavicular attachments; while the deltoid and 
trapezoid muscles, acting in opposite directions, neutralize each other's dis- 
turbing powers. Mr. Smith dissents from this opinion, thinking that its sup- 
porters " have been too much influenced by reasoning upon the anatomy of 
the parts concerned, and have not devoted sufficient attention to the pheno- 
mena disclosed by the post-mortem examination of the injury under consider- 
ation." — p. 210. His investigations have been conducted upon eight specimens; 
in five of these, the bone had been broken between the trapezoid ligament and 
the acromion process. In the remaining three, the fracture was situated be- 
tween the conoid and trapezoid ligaments. A brief history of these cases is 
presented in the text, and to some of them illustrative drawings are appended. 
His inferences, drawn from the symptoms and post-mortem appearances of these 
examples, may be thus summed up : " When the bone is broken between the 
coraco-clavicular ligaments, it is manifest that, if these structures have not 
been injured, there can be but little displacement of the fragments, according 
to the thickness of the bone, although there may be a slight derangement as 
regards its direction. The trapezius muscle will tend to draw the extremity 
of each fragment upwards, as the conoid and trapezoid ligaments will permit, 
and thus to increase the natural curve of the clavicle at the seat of the frac- 
ture. The convex form of this portion of the bone, superiorly, assists the 
trapezius in counteracting the tendency of the deltoid muscle to depress the 
fragments. The weight of the arm may cause a slight sinking of the outer 
fragment below the level of the inner ; but, as this displacement, for obvious 
reasons, can seldom be carried so far as to enable the broken surface of one 
fragment to clear that of the other, the overlapping of the two portions of the 
bone must necessarily be an exceedingly rare occurrence." — p. 215. 

But, when the fracture is external to the trapezoid ligament, the outer frag- 
ment becomes acted upon in two opposite directions. By the trapezius muscle, 
its inner extremity is drawn upwards and outwards, while the weight of the 
shoulder, and the muscles which most powerfully affect the position of the 
latter, throw its outer, or acromial end, downwards and inwards. Another 



132 Reviews. [Jan. 

source of derangement of the outer fragment exists in the revolutionary- 
movement upon its axis which the scapula is made to undergo, by the weight 
of the shoulder acting upon its superior external extremity, and by the greater 
rhomboid muscle drawing its inferior angle towards the spine. The effect of 
these combined forces and influences upon the outer fragment of the broken 
clavicle is to direct it so that a right angle is formed by the two fragments at 
their point of contact, the line of the inner portion of the bone remaining 
unchanged in its direction, while the axis of the outer inclines, from within, 
downwards, forwards, and outwards, and is somewhat in front of the other 
without overlapping it. 

In both cases, crepitus may generally be produced by moving the fragments 
in opposite directions. In the reparation of this fracture, bony matter is very 
freely deposited upon the under surface of each fragment, rarely upon the 
upper surface of either. The ossific formation sometimes is so profuse as to 
constitute bony props extending from the clavicle to the coracoid process of 
the scapula, and even to the notch; and sometimes anchylosis is thus esta- 
blished between the scapula and clavicle. 

In the sixth chapter, dislocations of the bones of the foot are noticed, and 
particularly " a dislocation of the metatarsus and internal cuneiform bone up- 
wards and backwards upon the tarsus. ^^ — pp. 224-237. 

Lastly, chapters are devoted to the subjects of congenital dislocations of the 
wrist and shoulder-joints, and of the lower jaw. — pp. 238-293. In these, the 
author has diplayed the same accuracy and minuteness of examination which 
characterize the preceding chapters. He has added new facts to the records 
of science, and has more clearly explained the conditions upon which these 
rare and interesting deformities depend. 

Mr. Smithes treatise may be considered one of our best models for con- 
ducting surgical observations. Since we first read Sir Astley Cooper's classic 
work on Dislocations and Fractures, we have met with no volume on the same 
subjects which has afforded us so much pleasure and instruction as this. And 
it is but due to the author to say that, in many instances, and in the more 
limited range of his topics of study, his treatise displays a more thorough and 
strict research, and greater power and quickness in argument, than that of the 
other celebrated surgeon. It has strengthened our conviction of the excellence 
of the Dublin '' School" of Medicine. F. W. S. 



Art. Xir. — On Infantile Laryngismus, with Observations on Artificial Feed- 
ing, as a frequent cause of this Complaint, and of other Convulsive Diseases 
of Infants. By James Reid, M.D., Member of the Royal College of 
Physicians of London; Physician to the G-eneral Lying-in Hospital, and 
to the Infirmary of St. Griles and St. G-eorge, Bloomsbury; formerly 
Lecturer on Obstetrics and the Diseases of Women and Children. London, 
1849 : 12mo. pp. 204. 

Although a disease of frequent occurrence in all large cities, and one 
marked by symptoms strikingly characteristic, it is somewhat remarkable that 
infantile laryngismus should only recently have attracted the attention of the 
profession to an extent which its importance and dangerous character demand. 



1850.] Reid on Infantile Laryngismus. 133 

It was not until the appearance of tlie work of Kopp, in 1830 (Denkwiir- 
digkeiten in der arztliclien Praxis); in which he advocates the doctrine of the 
whole chain of symptoms which characterize the disease being dependent 
upon an enlarged state of the thymus gland, that the attention of physicians 
appears to have been especially directed to the investigation of its pathology. 
Since then, several treatises, and numerous papers in the medical journals, 
have appeared, furnishing valuable materials for a better understanding of 
the nature of the disease, as well as its proper treatment and prophylaxis. 
For the most important contributions on the subject of infantile laryngismus, 
we are indebted to the physicians of G-ermany. Many excellent papers in 
reference to the disease have nevertheless appeared, within a few years past, 
in the medical periodicals of France and Great Britain. 

In the work before us, we have the observations of a practitioner having 
opportunities particularly favourable for the study of this affection, and whose 
views in relation to its pathology, management, and prevention, are of a cha- 
racter that will attract, we are persuaded, the attention of the profession 
generally. 

Dr. Keid describes infantile laryngismus as occurring under four different 
forms. T\\Q first is caused by a slight constriction of the edges of the rima 
glottidis, which occurrs suddenly, and in a transitory manner; causing, for 
the instant, an exertion on the part of the infant to recover its breath, and 
producing a feeling of oppression and alarm, indicated by a short cry, and the 
anxiety depicted on its countenance. 

*' The effect produced resembles that which may be observed when an infant 
is imprudently tossed up and down in the arms of a nurse or attendant, and 
is sometimes accompanied by a peculiar noise during inspiration, called a 
* catching in the breath.^ This slight and temporary spasm of the glottis is not 
associated with convulsive action of any other part of the body. The attacks 
come on at irregular intervals, and at uncertain times ; although, generally, the 
symptoms are more liable to occur whilst the infant is asleep, or at the moment 
of awaking. 

" So little importance is generally attached to this symptom by nurses, that the 
practitioner, when called on at an after period to treat the more severe form of 
the complaint, finds that the ' catching' alluded to is often not mentioned until 
questions are put, which at once recall the recollection of its having been of 
frequent occurrence, with the addition, that it was always arrested by lifting 
the infant from a recumbent to an erect position. 

" Second form. — In this variety, the area of the glottis is still more diminished 
by the nearer approximation of its margins, the closure, however, not being 
perfect, except, perhaps, for a moment. 

"There is now a much longer interruption to the respiratory function, and 
the symptoms of suffocation appear more imminent ; there is a violent struggle 
to inspire through the contracted aperture of the windpipe, in order to fill the 
lungs. The countenance presents the characteristics of great anxiety, with 
indications of distress, becoming at first red, but soon changing into the purple 
hue of strangulation ; the face becomes turgid and swollen, and the tongue, 
also, in some cases. In other instances, an ashy paleness of the face is ob- 
served. The arms are thrown out; the eyes appear either wide open and star- 
ing, or, more rarely, seem turned up in their sockets ; the nostrils are dilated ; 
the head is thrown back; the limbs become rigid, and the abdominal muscles 
contracted. There is frequently, also, a convulsive and violent action of 
other muscles, especially of the flexors, causing a peculiar contraction of the 
fingers and toes, as well as of the wrists and ankles, a state which has been 
called the carpo-iiedal spasm. In such cases, the thumb is bent in upon the 
palm, the fingers closing over it, whilst the toes and instep are bent downwards. 
Occasionally, the body itself is bent suddenly backwards, as if by a violent effort, 
and it appears to the bystanders as if nature could hold out no longer, when^ 



134 Reviews. f Jan. 

at length, the attempt at inspiration is partially successful, being attended by 
a shrill whooping noise, which has been termed * crowing,^ although it more 
closely resembles the concluding rising note produced by the clucking of a hen. 
This sound is not of so full and sonorous a character as that of hooping cough, 
but seems more acute, and without the rough hoarseness of croup. It is often 
an indication that the paroxysm has terminated, but in some cases a succession 
of incomplete or interrupted, shrill, sibilant catches supervenes before a suffi- 
cient inhalation takes place, as if the margins of the glottis were for a time 
somewhat relaxed, becoming immediately again constricted, so that the expira- 
tions bear, in some degree, a resemblance to the short and feeble bleatings of an 
animal. 

"When, however, respiration is again properly re-established, the infant ex- 
presses its fright and suffering by a fit of crying, and falls asleep. On other 
occasions, when the attack is unusually severe, a listlessness and torpor remain 
for a short period afterwards, whilst, in rarer instances of this disease, the 
child continues during some hours in an anxious state of distress. 

" These paroxysms vary much in their frequency, duration, and severity ; 
there is no regularity in the intervals between the attacks ; but, as the complaint 
advances, they generally become shorter, and, in some instances, do not continue 
beyond an hour at a time, or even half that period, the slightest noise or emotion 
being quite sufficient to produce a paroxysm. 

" The breathlessness, or struggling for air, is apparently relieved, in some 
cases, by a violent expulsion of wind from the stomach or ' per anum,' which 
is succeeded by a fit of screaming. Occasionally, also, there are involuntary 
evacuations during the paroxysm. 

"Kepeated attacks of this nature may occur, without the accompanying 
crowing noise, previously mentioned, especially when the disease becomes less 
severe in its character. 

" An acute, plaintive cry frequently commences or terminates the paroxysm, 
when the child remains quiet and subdued for some minutes, after which period, 
it resumes its natural cheerfulness and aspect, enjoying perfect health in the 
intervals. 

"The duration of iJie paroxysm varies from a few seconds to three or four 
minutes; but, in the latter description of cases, it is more a succession of 
paroxysms ; air occasionally gaining admittance into the lungs, during the 
slight and almost imperceptible intervals between them. 

"Remissions and exacerbations often take place for weeks, and sometimes for 
months, before a complete cure can be effected ; whilst in other cases, on the 
contrary, the complaint suddenly disappears. 

" Third form. — This is a combination of the foregoing variety of the disease, 
with the fearful addition of general or cerebral convulsions, which; in all proba- 
bility, are sometimes produced by the blood supplied to the brain being im- 
perfectly decarbonized, in consequence of partial asphyxia. 

^^ Fourth form. — Complete infantile spasmodic asphyxia, produced by a sudden 
and convulsive closure of the glottis, which proves as speedily fatal as if the 
infant were plunged under water, or strangled by a cord round its neck. In 
this form of the complaint, no crowing sound is audible, as inspiration is totally 
suspended, and the face of the child, instead of being flushed and turgid, ex- 
hibits often a cadaverous aspect, similar to the pallor and lividity of those as- 
phyxiated by carbonic acid gas, or other noxious vapours. An infant may 
have passed through numerous severe attacks of this dangerous disease, com- 
bined with cerebral convulsions ; it may be also, perhaps, improving otherwise 
in general health, at the same time that the paroxysms have latterly occurred 
at longer intervals ; yet, notwithstanding all the apparent amendment, it is 
sometimes in a moment carried off by this form of the disease, without any 
previous warning. The infant may be laughing at the time, or quietly observ- 
ing the occurrences taking place around it, without the slightest precursory 
symptoms being perceived. There exists, in such cases, perhaps, a combination 
of some hitherto unexplained and intense affection of the pneumogastric nerve, 
seeing that the mode of death now adverted to resembles forcibly the same 
quiet but sudden exit from life which is noticed in cases of angina pectoris, or 



1850.] Reid on Infantile Laryngismus. 135 

syncope anginosa. This marked resemblance in some degree warrants the 
conclusion that both are attributable to the same cause/^ 

The foregoing extracts present the best description of infantile laryngismus, 
in its several forms, from its mildest to its most severe and rapidly fatal, with 
which we are acquainted. We have given it entire, believing that the phe- 
nomena of the disease require a closer attention on the part of medical prac- 
titioners than is generally given to them. They are unquestionably of more 
frequent occurrence than many suppose, and, in numerous cases, as Dr. Reid 
very correctly remarks, while they imperceptibly increase in strength, " their 
advent is of such an insidious character that the disease has gained a strong 
hold upon the infant's constitution before its true nature is detected. '^ 

In regard to the age of infants most liable to the attacks of laryngismus, 
Dr. Reid states it, in common with nearly all who treat of the disease, to be, 
with few exceptions, that which corresponds to the period of dentition ; only 
two cases have occurred in his practice in which it continued after the appear- 
ance of all the deciduous teeth. Most of the Glerman writers state, as the usual 
period for the occurrence of the disease, from the age of three weeks to eighteen 
months, but more particularly between the fourth and tenth month. Dr. 
Copland limits the time to the age of three or four years, while Dr. Hugh 
Ley saw one case at four or five years, and another between six and seven, 
combined with extensive disease of the lungs. Porter witnessed an exceed- 
ingly well-marked example of laryngismus in a child nearly six years old, 
when recovering from hooping cough. In one case in which Dr. R. was 
consulted, the child, aged seventeen months, had been affected by the disease 
during the preceding seven months, and was carried off by a fatal paroxysm 
before a tooth had shown itself in either jaw. In another case which came 
under his care, the first symptoms of the disease appeared at the age of two 
and a half months, the patient being otherwise a fine healthy child, reared by 
hand; in this instance, it proved fatal at three and a half months. He like- 
wise witnessed an attack in an infant which was only two days old. In this 
case, the spasmodic action of the glottis, with loud crowing inspiration, was 
very apparent, and evidently depended on retained meconium, producing spinal 
irritation. He has, also, heard the crowing inspiration in a newly-born infant, 
within a few hours after its birth. The child was delivered by the forceps, after 
a very lingering labour. The crowing sound frequently recurred for more 
than three weeks afterwards; it generally came on when the infant was fatigued 
by crying, or much troubled with flatulence, and was especially remarked 
whilst it was affected for a few days with jaundice and disordered bowels. 

Sir H. Marsh mentions a case in which the infant was attacked, three days 
after birth, with a laryngeal spasm, and crowing inspiration of severe character, 
the paroxysms recurring at intervals, until the third month. The disease 
recurred between the fifth and sixth month, with general convulsions. No 
benefit resulting from any treatment, the child was removed to the country, 
when all the symptoms immediately ceased. 

"An affection/' remarks Dr. R., ''closely resembling spasm of the glottis, if 
not identically the same complaint, may be caused, at any period of life, by local 
or mechanical agency; but it must," he thinks, "be considered a peculiar dis- 
ease of infantile life, when it follows as the result of constitutional irritation.^' 

Dr. Reid notices a peculiar predisposition to the attacks of laryngismus, in 
consequence of which the children of certain families are more liable to its 
occurrence, under the same exciting causes, than those of other families. 
Locality, also, evidently possesses great influence in developing the malady. 
Respecting hereditary predisposition, we are as yet scarcely in a position to 



136 Reviews. [Jan. 

decide ; the attention of the profession having been so recently directed to the 
careful investigation of the disease. 

"As far as regards the aggression of laryngismus in connection with the 
scrofulous constitution, I have not myself/' Dr. R. states, "been able to trace 
any j^ecwZiVr relation between them ; for, although in some cases the children 
were perhaps of that diathesis, the symptoms of it were by no means strongly 
marked, and, in the majority of my cases, the fact was not observed at all. In 
the large number of children which, for many years, formerly came under my 
notice in the infirmary of St. Giles, frequent instances were observed, in which 
enlarged indurated cervical glands extended below the clavicle, and from their 
extent, and consequent effect upon the general health, at length caused a fatal 
termination; yet they were unaccompanied by the slightest appearance of laryn- 
gismus. In others, again, the disease attacked in succession the different joints, 
and gradually invaded the neck, thorax, groins, vertebr93, &c., without pro- 
ducing any signs of this complaint. 

*' We often observe, on the contrary, that strong, robust infants, without the 
least apparent scrofulous taint, have sufiered severely from these spasmodic 
attacks. 

"As a more general indication, I should venture to say that infants of a nerv- 
ous temperament, who are easily excited, who are awakened by slight noises, 
and who are not satisfied unless they are kept constantly ' on the move,' are 
much more susceptible of this affection than other children.'' 

This latter remark corresponds with our own experience. 

Dr. R. presents, in the next section of the work, an examination of each of 
the prominent characteristic symptoms of infantile laryngismus. The ob- 
servations presented under this head, though interesting, and calculated to 
lead to a correct diagnosis of the disease, we must pass by, in order that we 
may devote some attention to the author's consideration of the causes of this 
important malady. 

The direct or immediate cause of laryngismus is now generally admitted to 
be a spasmodic closure, to a greater or less extent in different cases, and in the 
progress of the same case, of the rima glottidis; but, in regard to the remote 
or exciting cause, there still exists a very great difference of opinion among 
those vrho treat of the disease. 

In regard to the cerebral cause of the disease, originally suggested by Dr. 
John Clarke, and advocated by Beatty, Cheyne, RuUman, Fricke, Oppenheim, 
Pretty, Burgess, Rees, and a number of other recent observers, Dr. E., 
while he admits that cerebral or general convulsions are often associated with 
laryngismus, and that a paroxysm of the latter may sometimes merge into 
the former, still he denies that the disease is dependent upon primary disease 
of the brain. 

"If," he remarks, "careful observation be made respecting this point, I 
think it will be found, in all cases, not complicated with cerebral convulsions. 

"First. That there are not present the usual symptoms of congestion of the 
brain. 

"Secondly. That, in the great majority of cases, no unusual pathological 
appearances in the brain are met with, after a fatal termination from spasm of 
the glottis. 

" Thirdly. That the remedies most successful in this complaint are not those 
which are usually employed in cerebral congestion ; whilst, on the contrary, 
those which are indicated have frequently been productive of great injury in 
the treatment of laryngismus." 

Dr. B. also thinks it may be fairly inferred that laryngismus is sometimes 
complicated with, or followed by, hydrocephalus, but that in very rare instances 
does the latter act as a cause of this affection. 



1850.] Reid on Infantile Laryngismus. 137 

That some direct aiFection of the pieumogastric nerve may be a cause of 
irritation, and even of partial closure of the glottis. Dr. E,. considers proved 
by a case, narrated by Sir A. Cooper, of inflammatory action of this nerve 
producing not only a convulsive or spasmodic cough^ but also the peculiar 
whooping noise of laryngismus. 

"Breschet," he observes, "found the colour of the pneumogastric nerves 
more yellow than natural, in the autopsies of a great number of cases which 
had terminated fatally from hooping cough ; whilst Gendrin remarked, in an- 
other case, in which these nerves were found denuded by an abscess, that there 
had previously existed a severe convulsive cough. 

*' Sir H. Marsh forms a conjecture that the seat of laryngismus may, perhaps, 
be found to exist at the origin of the pneumogastric nerve. It must be admitted, 
however, that, connected with this part of the subject, there is still open a wide 
field for investigation.^^ 

Dr. Ley's hypothesis, that laryngismus is the result of a paralysis of those 
agents whose office is to open the chink of the glottis, caused by the pressure 
exercised upon the nerves of the parts by enlarged cervical and bronchial 
glands. Dr. R., in common with nearly all who have written upon the dis- 
ease since the appearance of Dr. Ley's treatise, rejects, as one opposed by 
numerous facts, both positive and negative. In numerous dissections of those 
who have died of the disease, no particular enlargement of the glands 
referred to was detected; while, in children who have died from other dis- 
eases, and who showed not the slightest symptoms of laryngismus, these glands 
have been found very considerably enlarged. 

''Were this pressure from the enlarged glands a frequent cause of laryngis- 
mus, it is difficult to comprehend Avhy the attacks are often separated by long 
intervals in some cases, although the pressure continues the same. Such con- 
tinued pressure would also act as a direct mechanical cause, whereas, the his- 
tory of the disease proves it evidently to be the effect of reflex action. Dr. 
Marshall Hall asserts, moreover, ' that such pressure would cause permanent 
paralysis, and constant closure of the glottis.^ ^^ 

The sudden manner in which the paroxysm is resolved, in many severe 
cases of laryngismus, upon a change of air, the cutting of a tooth, the dis- 
charge of worms, or of large unhealthy stools, or the exhibition of antispas- 
modics, is inconsistent with the supposition of its dependence upon pressure 
from an enlarged and indurated gland. 

The experiments of modern physiologists, also, are directly opposed to this 
theory — 

" Since they show that the inferior or recurrent laryngeal nerves, which alone 
govern the muscles of the glottis, are exclusively motor nerves, and that irrita- 
tion, applied even to one of them, will produce convulsive closure of that aper- 
ture, whilst cutting or compressing them renders the glottis and movements of 
the arytenoid cartilages inert or passive, but does not prevent ingress or egress 
of air, although they impede the former.'' 

To the theory which ascribes laryngismus to enlargement or disease of the 
thymus gland, so strongly advocated by Kopp and Hirsch, of Konigsberg, Dr. 
R. adduces pretty much the same objections as those he opposes to the theory 
of Ley. Other objections of an equally forcible character may be adduced 
to the supposed thymic source of the disease. Thus, in many of the cases 
adduced in its support, there is no evidence that the thymus body was abnor- 
mally enlarged — the actual size of the organ differing materially in different 
infiints of the same age, in whom no evidences of disease are present. Many 
fatal cases of laryngismus have occurred in infants in whom the thymus body 



1S8 Reviews. [Jan. 

was much below what has been assumed as its average healthy size; and when 
cases of diseased and enlarged thymus have been accurately observed, thS 
symptoms to which it gave rise, as in those recorded by Dr. West, of London, 
were not those of laryngismus. If the thymus should be found of an un- 
usually large size in the generality of cases of the latter disease, which, how- 
ever, is not the case, this may be explained as a consequence of the frequent 
violent straining at inspiration during the attacks, acting strongly upon this 
part. 

"It is well known that an affection of a neighbouring gland — bronchocele, or 
hypertrophy of the thyroid — is frequently produced by violent exertions, such 
as long-continued attacks of vomiting, during pregnancy; and individuals ac- 
customed to use the voice much, such as the Muezzins of the East, the drill 
masters in the army, and others, are peculiarly liable to this affection, accord- 
ing to Baron Larrey. It is, then, not unreasonable to suppose that such intense 
and repeated forcible action on the cervical organs might produce similar re- 
sults in the more tender tissues of the infant." 

One of the most common causes of laryngismus, according to Dr. R., is a 
deranged state of the stomach and bowels. He has never known more than 
two instances of the complaint to occur without the presence of such derange- 
ment, indicated by constipation, a morbid condition of the stools, flatulence, 
&c. And it is seldom, he remarks, that we observe decided signs of ameliora- 
tion in the little patients, until the secretions become of a more healthy cha- 
racter. In fact, most of the writers upon the disease, whatever may be the 
difference in their views as regards its cause, admit that a vitiated state of 
the alvine secretions is a prominent symptom, some describing this as aggra- 
vating the disease, whilst others view the disordered condition of the bowels 
as a primary cause. 

Another cause which experience convinces us, if it be not alone sufficient 
to originate laryngismus, at least materially aids in keeping up the irritation 
which has been produced by other causes, is atmospheric influence. This is 
proved by the fact that, in many cases of the disease, on a change of air, the 
symptoms have immediately ceased, but recurred when the infant was brought 
back to its former residence. 

*' The rare occurrence of the complaint in country districts," remarks Dr. 
E., " as compared with its prevalence in crowded towns, is another proof that 
atmospheric influence is concerned, in the majority of cases, as one of the excit- 
ing causes. Medical friends, who had resided for upwards of twenty years in 
agricultural districts, have assured me that they never saw, during that period, 
a single instance of laryngismus, but that, since they had removed to London, 
several such cases have fallen under their notice." 

" This fact may be readily explained by the great irritability of the motor 
nerves of the glottis, in cases of laryngismus ; a predisposition to the disease 
already exists, perhaps, arising from irritation of the bowels, whilst the con- 
stant entrance of an atmosphere loaded with smoke, and other noxious particles, 
through the sensitive aperture, will naturally still further increase the local 
excitability, and thus tend to the more frequent aggression of the spasmodic 
paroxysms. 

"The disease is often thus maintained, after the original exciting cause has 
disappeared, and it is, in such instances, most likely, that a removal into pure 
country air is attended by an immediate cessation of all the symptoms. 

" This is the 'mechanicaF explanation of atmospheric influence on the local 
spasmodic affection; but we must also take into consideration the good effect 
often produced by ' change of air,' not only upon those who are labouring under 
disorders of the respiratory apparatus, but in as marked a manner on individuals 
suffering from functional derangement of the stomach, or of the nervous system." 



1850.] Reid on Infantile Laryngismi. 139 

The returns of the mortality in 117 districts of England is adduced to prove 
that the mortality of infants, during the age of teething, is six times greater 
in town than that met with in an equal population of a country district. 

It has been supposed that a damp or low locality, even in the country, is 
apt to give rise to laryngismus. Dr. R. considers that, under certain circum- 
stances, it may, perhaps, have some effect, in combination with other causes, 
but that its influence cannot be very powerful. Some, as yet undetected, local 
influence has, at all times, no doubt, much to do in assisting to generate the 
disease in certain situations. Dr. Hall mentioned, at a discussion at the Lon- 
don Medical Society, that he had known of three fatal cases of laryngismus 
occurring in a family who resided upwards of four miles from a large country 
town; the other infants of the same family were, on this account, at after 
times, removed from the place, and thus escaped the disease. 

Dr. E.. can find no decisive proof that cold weather has any prejudicial effect 
on cases of laryngismus. In more than one case, he has known a removal 
from town to Hampstead Heath, or to the coast, during the cold, bleak 
winds of spring, immediately to arrest the complaint. In one instance, it was 
found that exposure to the open air in cold weather invariably stopped the 
paroxysms, and that one of them never occurred during such exposure. 

Peculiar odours seem, occasionally, to act as a sufficient cause for inducing 
the paroxysms of the disease. Cases are referred to in which the paroxysms 
were caused by the fumes of alcohol, the atmosphere of a newly-painted room ; 
and a great number of similar cases could be cited. 

After a careful consideration of all the cases of laryngismus which have 
fallen under his own notice, and of those which are detailed by others. Dr. B,. 
adopts the following conclusions in reference to the pathology of the disease : — 

" 1. That, for the occurrence of this complaint, the cerebro-spinal system is 
required to be in a peculiarly excitable state, which thus acts as a predisposing 
cause. The period of ' teething' is the most likely one to produce this con- 
dition. 

"2. That, during this irritable state of the nervous centres, the two most fre- 
quent (and, in the majority of instances, the combined) causes are the impro- 
per description of food, which is administered to the infant, and the impure and 
irritating atmosphere which it breathes.'' 

Under the head of improper food, may, in certain circumstances, be included 
the breast milk of the mother or nurse. That is, when, from any cause, this 
has become deteriorated. Dr. R. believes, however, that comparatively few 
cases of laryngismus occur in infants who are fed altogether upon breast 
milk. 

"Of the numerous instances which have come under my notice at various 
times," remarks Dr. K., "this disease has occurred in two infants only who 
were not fed by hand, either altogether or partially ; one of these was a child, 
six months old, who had a wet nurse ; by a curious coincidence, the nurse her- 
self, two nights previously to the child being affected, had a similar spasmodic 
affection of the glottis, caused by hysteria, and the sound produced by it so 
precisely resembled that which the father of the infant (a medical practitioner) 
had been accustomed to hear whilst his elder children had suffered from laryn- 
gismus, that he hastened up stairs, thinking the infant was also attacked by it. 
Two days after this, the child, for the first time, did show symptoms of the dis- 
ease, although they were slight, and of short duration, compared with those of 
the other children." 

Some very important remarks follow on the subject of rearing infants by 
hand. Dr. K. shows, by a number of interesting statistics, the very great aug- 
mentation of the mortality among children who are deprived of the breast, and 



140 Reviews. [Jan. 

attempted to be brought up upon artificial food, compared with those who are 
confined exclusively to the breast. 

Numerous authorities are cited to prove that children who are nourished at 
the breast exclusively, until dentition has made some advance, are much less 
liable, under all circumstances, to be attacked by laryngismus than those who 
are brought up by hand, or whilst at the breast are furnished with artificial 
food. The whole of the remarks of the author, under this head, are interest- 
ing and important. 

The diagnosis of laryngismus is next laid down. It has been confounded 
with croup. But in laryngismus there are no previous catarrhal symptoms, as 
in croup. It occurs, in the majority of cases, before the eighteenth month, 
and, most frequently, between the sixth and fourteenth months. It mostly 
attacks infants of a nervous and irritable temperament, and is unattended 
with inflammatory or febrile symptoms. The attacks may occur during 
the day or night, bat are most common in the morning. Respiration is 
perfect during the intervals. Cough is only an accidental accompaniment of 
the disease, and has then nothing peculiar. The paroxysms may be excited 
by mental emotions. The crowing inspiration is not hoarse, rough, or grating. 
The paroxysms are of a convulsive character, and frequently accompanied with 
spasmodic closure of the fingers and toes. There is no dyspnoea in the in- 
tervals. Laryngismus is not more prevalent than usual during damp weather. 
It is far more common in towns than in rural districts. It is purely a spas- 
modic disease. 

Croup is essentially of an inflammatory character — is usually preceded by 
catarrhal symptoms, dyspnoea, and a hoarse cough. The voice, at first deeper 
in tone, is, after the attack, sometimes almost lost, or has a squeaking cha- 
racter. There is a stridulous inspiration, like that observed in the adult during 
an attack of laryngitis. The whooping noise of laryngismus is not attendant, 
as in croup, upon cough, and has not the rough and hoarse sound which it has 
in the latter disease. Croup seldom attacks previous to the second year. The 
paroxysms come on almost invariably during the night, and are unattended 
with spasmodic contraction of the extremities. Croup is dependent upon a 
diphtheritic exudation upon the surface of the larynx and trachea. It is com- 
monly observed along the sea coast, or in low, damp situations. It is com- 
paratively rare in towns. The dyspnoea and cough continue during the 
intervals of the paroxysms. 

The diagnosis between laryngismus and hydrocephalus is mainly to be de- 
rived from the fact that the latter seldom attacks healthy and robust children. 
The disease generally comes on slowly, and after manifest symptoms of deterio- 
rated health. The same indications of intestinal disease are usually present as 
in laryngismus, but the abdomen in general presents a more sunken appearance 
than in the latter complaint. "The crowing noise of inspiration is so rarely 
heard in hydrocephalus, that," Dr. H. thinks, "it may be looked upon as pe- 
culiarly indicative of laryngismus. '^ Acute hydrocephalus is more liable to 
occur after than during the first year of childhood. In chronic hydrocephalus, 
the peculiar symptoms are of too striking a character to allow of any difficulty 
in distinguishing it from laryngismus. 

From hooping cough laryngismus is to be distinguished by the absence 
in the latter of the convulsive cough, retching, vomiting, or free expectora- 
tion, which so generally terminate the paroxysm in pertussis. Hooping cough 
is more gradual in its approach, is generally preceded by catarrhal and febrile 
symptoms, and the fits of coughing come on frequently during the day. 

The prognosis in this disease must, in every case, be somewhat uncertain, for 



1850.] Reid on Infantile Laryngismus. 141 

it occasionally proceeds in a mild manner for a time, and tlien suddenly assumes 
the most dangerous form. In more than one instance, Dr. K. has known an 
infant carried off by the spasmodic closure of the windpipe, when little or no 
danger was anticipated. There are no regular intervals between the attacks, 
and a sudden and very severe paroxysm may unexpectedly occur at any mo- 
ment, particularly during the period of dentition. The principal dangers to 
be apprehended are suffocation and cerebral convulsions. Thus, the prognosis 
will be worse when the child is constantly dull and heavy, with sluggish pupil, 
and signs of venous congestion about the head. Should there be any family 
tendency to cerebral disease, the prognosis assumes a still worse aspect. An 
unhealthy state of the mesenteric glands augments the danger of the disease, 
as also the occurrence of acute bronchitis, though, in one of the cases narrated 
by Dr. R., the crowing noise disappeared during an attack of bronchitis, and 
returned after it was subdued. 

" The duration of laryngismus is variable ; the little patient may be carried 
off by the first attack, although this is a rare occurrence; in other instances, as 
in one related by llullman, the child may struggle through the disease for twenty 
months, and then fall a victim to its effects.'^ 

The mortality in this complaint varies considerably in the statements of 
those authors who have described it. 

Dr. Grooch states that the disease proves fatal in one-third of those attacked ; 
but this. Dr. K. observes, is a far greater proportion than has occurred within 
his observation, for, out of fifty cases that have come under his notice, six only 
proved fatal. These were all male infants, and fed hy liand. The earliest 
period of life at which death took place was three months and a half, the 
latest, seventeen months. One of these cases was complicated with hooping- 
cough and bronchitis. 

In Sir H. Marsh's cases, five recovered and two proved fiital. In Hirsch^s 
cases, three out of five died ; one complicated with hooping cough, and the 
two others with general convulsions. 

Dr. Hugh Ley considers the disease to be ^^ not very commonly fatal ;'^ 
whilst Dr. H. Davies states it to be frequently so, especially when complicated 
with convulsions. Dr. Davies also considers the danger from the disease greater 
during the period of dentition, which accords v^^ith the experience of Dr. lieid. 

Dr. Reid's experience leads him to consider the disease more likely to 
prove fatal in male children than in female; but, according to Pagenstecher, 
Hackmann, and others, it attacks boys much more frequently than girls. 

"It is astonishing,'^ remarks Dr. li., "in some cases, how many attacks of 
the spasms and convulsions combined may take place during the twenty-four 
hours, without proving fatal. I have known them to occur on every slight 
noise in the room, so that the mere gentle displacement of any article on the 
table would cause a paroxysm, and yet a favourable termination of the disease 
ensue." 

It has been supposed that laryngismus is a much more frequent disease than 
'^>- formerly ; but it is more likely that its apparent increased frequency results from 
its true character being more generally recognized, since the attention of the 
profession has been directed towards its peculiar symptoms. 

In relation to the post-mortem appearances in those who have fallen victims 
to laryngismus. Dr. R. states that, on several occasions, he has sought for 
indications of disease, but has been unable to detect any, even in the spinal 
cord. As a general rule, it may be stated that no unusual appearances are 
found to exist in the glottis itself, or in the adjacent parts; no trace of oedema^ 
No. XXXVII.— January, 1850. 10 



142 Revieics. [Jan 

inflammatory action, or persistent constriction. Dr. R. has never met with 
any enlargement of the neighbouring glands sufficient to account for a fatal 
termination. In one of IMr. Powell's cases, however, the thyroid gland was 
preternaturally enlarged, its left lobe not only pressing the carotid artery out 
of its proper direction, but resting also on the recurrent nerves ; the cervical 
glands were large, but the glottis presented no unusual appearance. 

" In the cerebral organs, no greater amount of pathological change is observed 
than might be reasonably expected to accompany any case of sudden death, 
and, as already observed, it will sometimes happen that none whatever can be 
detected. As, in asphyxia from other causes, different effects are produced on 
the brain and heart in individual cases, so Avill they be observed also in laryngis- 
mus. '' 

Dr. R. thinks that sufficient attention has not been paid to the state of the 
intestinal mucous membrane in fatal cases of laryngismus. Mr. Ridout has 
informed him that, in one case which he carefully examined, the only morbid 
appearances detected were " ulcerated patches in the small intestines near the 
ileo-c8ecal valve." 

From all the evidence drawn from post-mortem examinations, Dr. R. con- 
siders that spasm of the glottis, in the great majority of cases, is dependent 
solely on 'Afunctional disorder." The frequent transitory character of the 
symptoms would, he thinks, denote also that the number of cases which 
originate from any organic change of structure must be very small. 

In regard to the treatment. Dr. R. recommends, during the paroxysm, hot 
water to the lower parts of the body ; cold affusion to the head ; the forcible 
sprinkling of cold water in the face; slapping the chest and nates; blowing 
in the face at intervals ; exposure of the child to the current of air at an 
open window. When the asphyxia continues for a lengthened period, arti- 
ficial respiration, by blowing at intervals into the child's mouth, closing at 
the same time the nostrils, pressing the trachea against the oesophagus, and 
afterwards compressing the thorax and abdomen with the hands — thus alter- 
nating the imitation of inspiration and expiration. 

''As our principal object, during these paroxysms, is to overcome the spasmo- 
dic rigidity of the muscles acting on the glottis, the inhalation of the vapour of 
ether may be had recourse to, provided any degree of respiration is still carried 
on; the vapour of ammonia may also be applied to the nostrils. Stimulating 
enemata have been tried in some cases with advantage, on such occasions, and 
the spine should be rubbed with spirit, or any other stimulant which may be at 
hand. It has been a question whether, in severe cases of laryngismus, the ope- 
ration of tracheotomy should not be performed ; it is one which will admit of 
argument, for we know that, in some apparently hopeless instances, the infant 
recovers, after a considerable time, under the usual means, and it is, therefore, 
incumbent on us not to resort too hurriedly to the employment of such a severe 
remedy ; on the other hand, the operation, to be of service, must not be too long 
delayed. There is, therefore, a choice of difficulties ; but, as an argument against 
the operation, it will be prudent to recollect that, in the cases narrated by Dr. 
Budd, and others, where death occurred in adults under somewhat similar cir- 
cumstances, this opening of the trachea was speedily resorted to by the medical 
officers who were on the spot, but without any good effect. In these cases, too, 
the spasmodic closure of the windpipe was owing to local causes alone, whilst 
in infantile laryngismus it is complicated with serious disturbance of other dis- 
tant organs." 

In all cases of laryngismus. Dr. R. directs a careful examination into the 
state of the gums, and if they be found full and swollen, inflamed, or give 
evidence, in any way, that much irritation exists at one part, their free divi- 



r 



1850.] Reid on Infantile Laryngismus. 143 

sion with the lancet, so as to relieve the tension of the gnm, and, if possible, 
that of the investing membrane of the tooth also. In the repetition of the 
operation, we must be guided by the same rules which would, in other cases, 
induce us to have recourse again to the remedy. Dr. R. is opposed to too 
frequent a repetition of the operation, believing that the irritation thus in- 
duced will cause as much mischief as that of the teeth themselves — of one 
fact he is quite certain, that the mental irritation excited by the mere appear- 
ance of the operator will, of itself, prove highly injurious, when he is recog- 
nized as the harbinger of approaching suffering. 

When the paroxysms are observed long before the teeth are near the sur- 
face of the gum, the operation would be out of the question. 

The great importance of avoiding all unnecessary excitement of the infant, 
whilst liable to this disease, should render us cautious not to irritate it by 
unnecessary examinations; the mere act of looking at the gums, by forcibly 
opening its mouth, will sometimes induce a severe attack. 

The abstraction of blood Dr. E,. considers inadmissible in the treatment 
of a simple case of laryngismus. Even when complicated with general con- 
vulsions, he enjoins much caution in resorting to blood-letting, and would 
confine it, under such circumstances, to the application of a very few leeches 
to the head. 

According to Dr. R., the symptoms indicating the employment of depletion 
are, elevation of the anterior fontanelle ; turgescence of the veins running 
across the scalp; flushed face; quick, strong pulse; great wakefulness; into- 
lerance of light and noise ; great heat of head ; or much stupor and sleepiness ; 
slow, full pulse, dilated pupils, half closed eyes, strabismus, or difference in 
size of pupils, and twitching of hands and feet. Even in such instances, how- 
ever, he thinks that the constant application of the cold spirit lotion to the 
head, or allowing a small stream of cold water to run for some minutes on it 
— enveloping the lower portions of the child in a blanket wrung out of hot 
water; an enema of warm soap and water; frequently dashing cold water in 
the face, and the use of the ice cap, will be attended with more benefit than 
the employment of repeated depletions. A free evacuation, also, of the con- 
tents of the stomach and bowels is more necessary in such cases than in the 
simple form of the complaint. In some of these cases, Dr. R. considers that 
a blister applied between the shoulders, with a piece of tissue paper or thin 
gauze interposed between it and the skin, and kept on for two or three hours, 
will be preferable to the repeated application of leeches to the head, Grreat 
care is required in the application of even a few leeches, in some cases of 
laryngismus. Exceptional cases, he remarks, may, perhaps, occasionally pre- 
sent themselves, as requiring more active depletion ; but these, he adds, will 
not invalidate the general rule. 

When an attack of laryngismus supervenes on over repletion of the sto- 
mach, which is sometimes the case, emetics. Dr. R. thinks, may be advisable; 
but, under other circumstances, he fears they would be more likely to prove 
hurtful than productive of any good effect. 

Regarding, as Dr. R. does, intestinal irritation as the most frequent cause 
of the disease, it will naturally follow that, with him, the removal of this 
cause should be the means first adopted for its cure. 

" In many cases/' he remarks, " a complete evacuation of the bowels is alone 
sufficient to remove the symptoms altogether, whilst, in others, it has a tem- 
porary effect only, especially if an injudicious system of feeding should be still 
pursued. When the paroxysms are severe, and danger imminent, a dose of 
calomel, proportioned to the age of the child, should be given, followed, in two 



144 Reviews. [Jan. 

or three hours, by a teaspoonful or more of castor oil ; the lower bowels may, 
in the meanwhile, be well emptied by an enema of soapy water alone, or with 
the addition to it of a little castor oil and common salt. It is astonishing, in 
some instances, what large and copious evacuations of thick, tenacious feces 
now take place ; and this effect continues, perhaps, for the space of two or three 
days, if the mercurial preparations are given regularly in smaller doses, com- 
bined either with gentle saline aperients, such as the potassse sulphas, the 
potassse tartras, or with a repetition of the castor q\V 

The proof of the proper action of the mercurial purgative will be evinced 
by the clay or putty-like viscid dejections being replaced by the usual yel- 
low, or orange-coloured evacuations of infants ) this change, we are told, is 
not unfrequently the first proof of amendment in the case. 

" After," Dr. R. proceeds to say, " having given one or more brisk purges of 
calomel, combined with rhubarb or scammony, it will be still advisable to con- 
tinue the same mercurial remedy in alterative doses of half a grain, twice daily, 
so as to gently stimulate the liver : and, as acidity in the primae vise is present 
in the great majority of cases, the addition of two or three grains of bicarbon- 
ate of potass or soda will generally be found advantageous. 

" The combination of alkalies with the purgative remedies is especially indi- 
cated in the treatment of laryngismus ; and, on this account, lime-water, am- 
monia in its different preparations, &c., should be given in conjunction with 
them. The enemata, also, should be repeated, with an occasional dose either 
of castor oil or of the infusion of senna with manna. 

" With regard to the strength of the aperients, an observation of the late Dr. 
John Clarke should be borne in mind : that ' children require much larger doses 
of purgative medicines, in proportion to their age, than adults.' Still, no severe 
cathartic effect is required, as our aim should be merely to unload the intestines 
of the constipated masses generally contained in them, to regulate the secretions, 
and to remove undue acidity and flatulence. The compound decoction of aloes 
will be found extremely useful on this account, as being a warm carminative 
aperient, and containing an alkali. The addition of an extra quantity of liquor- 
ice will, however, be requisite, in order to render it palatable to infants.'^ 

Dr. R. considers both the internal and external use of antispasmodics as 
invaluable in the treatment of laryngismus. " Assafetida or muskwill,^^ he 
remarks, " occasionally succeed in arresting the symptoms in some cases of 
simple convulsions arising from dentition, when leeching and purging have 
not alone had the desired effect.^' 

*' In those cases where the bowels are in a very irritable state, the exhibition 
of a small dose of hyoscyamus, Dover's powder, the hydrocyanic acid, ammo- 
nia, or the combination of them, will often produce a most striking effect in 
subduing the tendency to the spasmodic paroxysm." 

The following prescription is one which Dr. R. has been in the habit, lat- 
terly, of employing with excellent results : R. — Spiritus ammonias fcetidi ^ss; 
tincturse hyoscyami gtt. x; syrupi aurantii ^ss; spiriti anisi 5J ; acidi 
hydrocyanici diluti gtt. v; aquae ^j. — M. A teaspoonful to be given, three 
times a-day, to a child ten or twelve months old ; the doses being graduated 
according to the age of the patient. 

Should the above not prove speedily efficacious, the following formula may 
be tried: R. — Pulveris valeriani '^\y, ammonias sesquicarbonatis gr. viij ; 
syrupi aurantii ^ss; aq. carui ^iss. — M. To be well rubbed together. The 
sixth part to be taken as a dose three times a-day. 

A stimulating embrocation, with the addition of some narcotic, applied to 
the spine, chest, and abdomen. Dr. R. recommends as productive of decided 
benefit ; especially when the hands and feet are affected with spasmodic con- 
tractions. The following is Dr. R.'s usual formula : R. — Tincturge opii 5iss; 



/ 



1850.] Keid on Infantile Laryngismus. 145 

tincturge lyttae 5J ', liniment, saponis ^iss. — M. To be applied two or three 
times a-day. The addition of four grains extractum belladonnas; or 5ss of 
the tinct. aconitinse, in obstinate cases, will increase the effect. 

When the large bowels are distended with flatus, an enema of soapy water, 
containing Jss of tinct. assafoetidas, injected into the rectum once or twice 
daily, will often be followed by marked benefit. 

" In the secondary part of the treatment, tonics," remarks Dr. R., "will fre- 
quently be found to possess great influence in removing the lingering symptoms 
of laryngismus. The difi'erent preparations of iron and bark are those best 
adapted for the purpose, when purgatives and antispasmodic medicines have 
previously prepared the way for their employment. Some judgment, however, 
is requisite in selecting the appropriate time for commencing their use. 

" Sir H. Marsh has recommended half grain doses of quinine every six hours, 
for infants under one year old. In some cases, I have found the tinct. cinchonse, 
in doses of twenty drops every six hours, answer the purpose very well, but I 
have preferred, generally, the liquor cinchonge cordifolise of Battley in doses of 
five or six drops, three times daily, made palatable by the addition of syrup of 
orange-peel. Bullock's ferro-citrate of quinine will answer our purpose admi- 
rably, when a combination of the tonics is thought necessary. 

" Among the different preparations of iron, I still prefer the vinum ferri of 
the old London Pharmacopoeia; but the ammonia-citrate and the potassio- tar- 
trate are, owing to their comparatively slight taste, eligible forms of the same 
mineral, as they do not nauseate the little patient. In those cases which are 
really combined with a scrofulous taint, the syrupus ferri iodidi may be advan- 
tageously employed.''' 

Attention to the diet of the infant is all important. The confinement of 
the infant to the breast-milk of a healthy nurse, during the ordinary period 
of suckling, cannot be too strongly insisted on. In individual cases, it will 
be advisable to continue this mode of nourishment even beyond the usual 
period. If the mother's or nurse's milk is suspected to be deteriorated in 
quality, no time should be lost in placing it at a breast from which it will be 
supplied with a more healthy nutriment. 

The directions given by Dr. R. for the proper management of the period of 
suckling are highly judicious, but contain nothing new. The same maybe said 
of his remarks on weaning. 

'' It is not essential that weaning should be had recourse to," says Dr. R., 
''because the mother finds her milk is diminished in quantity, and is insuffi- 
cient for the sole support of the child. AVith some infants, the combination of 
the breast-milk and thin farinaceous food seems to agree very well ; and I 
have known several instances in which the latter was taken with benefit, whilst 
the mother was enabled to suckle twice only during the twenty-four hours : but 
immediately that weaning was resorted to, and the infant thus depended on 
artificial food alone, derangement of the bowels supervened, and the general 
health appeared to suffer. On this account, it is of importance, in cases where 
there is a predisposition to laryngismus, that, in place of weaning altogether, the 
occasional meal of breast-milk should be continued to as late a period as pos- 
sible. 

" The bad effects of weaning are not in general immediately observed; two 
or three weeks often elapse before they become visible ; and I have known 
numerous cases of laryngismus to occur about this period. It is at least advis- 
able that the time of weaning should be deferred as long as possible in all 
cases where either laryngismus or cerebral convulsions have once occurred ; the 
benefit resulting from this precaution has been fully proved by the case just 
related. As a general rule, I would recommend that a child subject to laryn- 
gismus should draw its principal subsistence from the breast until it attains its 
twentieth month, and it would be better in extreme cases to defer weaning 
altogether even for some months longer." 



s 



> 
f 



146 Reviews. [Jan. 

We very mucli doubt the propriety of tlie latter suggestion — we should 
rather fear injury than good to result to the infant from protracted suckling ; 
and when fed, in great part, upon proper artificial food, we cannot see any 
benefit that can be derived from the occasional application of it to the breast. 

This portion of the treatise closes with some admirable directions in relation 
to feeding by hand, when this has unavoidably to be resorted to. The cor- 
rectness of the following remarks our own experience fully corroborates : — 

" No universal rule will hold good as to the diet of children. Some infants 
require food more nutritious in quality, and in larger quantities, than others of 
the same age. Those who are much accustomed to witness the treatment of 
infants are aware, that a description of food which agrees perfectly well with 
one child will totally disagree with another, and hence, any article of diet 
which appears to suit the infant, should not be needlessly changed.^' 

In regard to change of air, a very important point in the treatment of in- 
fants liable to attacks of laryngismus, the author presents a number of judi- 
cious suggestions. At all times, and under all circumstances, a free, pure 
air, of sufficient warmth in winter, and cool in summer, is all important^ but 
particularly so in the case of those subject to paroxysms of laryngismus. 

Confined air about the infant's bed is extremely prejudicial in cases of 
laryngismus. So impressed has Dr. R. always been with this opinion, that, in 
several instances, he has had the infant removed down into the more spacious 
drawing-rooms during the greater portion of the twenty-four hours, and with 
marked advantage. 

'' In fine weather," the author remarks, "it is advisable to keep the little 
invalid out of doors, for some length of time, daily ; the fresh air allays irrita- 
bility, and is equally advantageous as with children who are suffering simply 
from the process of dentition; they appear to be soothed by respiring it, and 
those who have been restless and fretful whilst in the house, then often sink 
into a peaceful slumber of some duration. It is not advisable, however, to fol- 
low this course when the atmospheric changes are rapid and severe. 

"In some cases of laryngismus, a removal to the country is absolutely indis- 
pensable, in order to save the infant's life ; and, in extreme instances even, it 
has produced an immediate good efiect. When the general health is much im- 
proved, but the spasmodic action of the glottis still lingers, and is not subdued 
either by medicine or regimen, change of air will generally complete the cure. 
Dr. M. Hall mentions a remarkable case of this description, which arose, appa- 
rently, from a state of torpor or constipation of the bowels ; it had been a severe 
case attended by emprosthotonos, and, although it seemed to linger during the 
use of other remedies, change of air suddenly removed the disease. In hoop- 
ing cough, the same occurrence frequently takes place. 

" I have sometimes found that, when a removal to one locality has not been 
attended with the expected favourable result, a still further change has soon 
proved beneficial.^'' 

Appended to the work, are the details of twenty-six cases of laryngismus — 
which illustrate very forcibly the observations upon the nature and causes of 
the disease, and the principles of treatment contained in the body of the treat- 
ise. To those who desire a useful manual upon the disease in question, we 
can recommend, very confidently, the work of Dr. Reid. We know of none 
better calculated to impart correct views in relation to its pathology and the- 
rapeutics. 

D. R C. 



f 

r 



1850.] 147 



BIBLIOGRAPHICAL NOTICES. 



Art. XIII. — A Practical Treatise on the Diseases of Children. By D. Francis 
CoNDiE, M. D., Secretary of the College of Physicians, Member of the Ameri- 
can Medical Association, Member of the American Philosophical Society, 
Honorary Member of the Philadelphia Medical Society, &c. Third edition, 
revised and augmented. Philadelphia, Lea & Blanchard, 1850: 8vo. pp. 
703. 

The favourable opinion -which we expressed of this treatise on its first appear- 
ance has now been endorsed by the verdict of the profession, two large editions 
of the work having been exhausted in comparatively a short period. 

"In the preparation of a third edition of the present treatise," the author ob- 
serves, " every portion of it has been subjected to a careful revision. A new 
chapter has been added on Epidemic Meningitis, a disease which, although not 
confined to children, occurs more frequently in them than in a,dults. In the 
other chapters of the work, all the more important facts that have been developed 
since the appearance of the last edition, in reference to the nature, diagnosis, 
and treatment of the several diseases of which they treat, have been incorpo- 
rated. The great object of the author has been to present, in each succeeding 
edition, as full and connected a view as possible of the actual state of the patho- 
logy and therapeutics of those affections which most usually occur between birth 
and puberty." 

One of the most important chapters in the work is that on the Hygienic 
Management of Children, a subject upon which there exists a lamentable degree 
of ignorance even at the present time. Although the observations of Dr. Condie 
upon this subject have been so long before the profession, yet, as there are no 
doubt many by whom they have not been read, and as they contain so much 
truth, we venture to extract the following: — 

" These remarks, made upwards of a century since, by one whose writings 
have been consigned to unmerited oblivion, are still substantially true. Avast 
amount of the disease and suffering that occur in early life is unquestionably 
produced by errors committed in regard to diet, clothing, and exercise — by im- 
pure air, unwholesome dwellings, imprudent exposure, and a general neglect of 
physical and moral education. Even now the proper management of infancy 
and childhood is but imperfectly understood, and many erroneous opinions in 
relation to it, giving birth to practices the most pernicious, are entertained, even 
by physicians. A general view of the most important particulars Avould seem, 
therefore, to be a proper and necessary introduction to the consideration of the 
pathology and treatment of the maladies incident to the early periods of life. 

"1. Air, Temperature. — The first want of a new-born infant is a free supply 
of air, and this want continues to recur during every moment of its future exist- 
ence. But it is not only necessary that the infant should be supplied with a 
sufficient amount of air to carry on the function of respiration ; it is equally 
necessary that the air it breathes be perfectly pure; an impure and stagnant 
atmosphere being even more deleterious, during infancy and childhood, than in 
more advanced life. From this cause alone, according to the statements of Br. 
Clarke, in the year 1782, out of 7650 infants, born in the lying-in hospital of 
Dublin, 2944 were destroyed within the first two weeks after their birth. They 
nearly all died in convulsions ; many of them foamed at the mouth ; their 
thumbs were drawn into the palms of their hands ; their jaws were locked, and 
their faces swollen and of a bluish tint, as though they had been strangled. So 
soon as proper measures were taken, at the suggestion of Dr. Clarke, to insure 

\ 



148 BihliograpMcal Notices. [Jan. 

a free circulation of air throughout the wards of the hospital, the dreadful mor- 
tality that had previously occurred among the infants inhabiting them was 
almost immediately suspended. Even when not immediately productive of 
any violent or fatal train of symptoms, by gradually impairing the powers of 
life, a vitiated and stagnant atmosphere produces a general unhealthy condition 
of the organs, prevents their due development, and lays the foundation for mala- 
dies that are always difficult, and often impossible, to remove. Children that 
have been from any cause confined in small, unclean, badly-ventilated, or over- 
crowded apartments, almost invariably exhibit the deleterious influence of an 
impure and stagnant air, in their pallid countenances, flaccid muscles, and 
emaciated limbs ; their impaired digestion, their panting respiration upon any 
trifling exertion, their stunted growth and sickly appearance generally, as well 
as their predisposition to some of the most dangerous aflFections of the lungs, 
stomach, brain, and other organs. There is no doubt that, in these cases, the 
injurious effects of a vitiated atmosphere are, in some degree, augmented by the 
want of proper and sufiicient exercise ; it would be in vain, however, to attempt 
to counteract them by any amount of exercise, so long as the little sufferers are 
debarred from enjoying the pure fresh air. 

" From the period when a child becomes able to walk alone, it should be 
allowed to pass many hours every day in the open air. The robust, fully deve- 
loped, and active limbs, and the ruddy and sprightly complexion, exhibited by 
children who pass much of their time in the open air, form a striking contrast 
with the pallid countenances, the general listlessness, the fragile frames, and 
the inactive disposition of those who are confined nearly the whole day within 
doors. 

" The temperature of the air to which infants and young children are exposed, 
is equally important with its purity. It has been shown by Dr. W. F. Edwards 
that, in the young of the human species, as well as of the warm-blooded animals 
generally, the power of generating heat is but imperfectly developed, and that, 
consequently, not only is the temperature of their body less, but their capability 
of resisting the depressing influence of cold is far below what it is in after life. 
We can readily perceive, therefore, that the exposure to air of too low a tempe- 
rature must be prejudicial to young infants; and, although the power of pro- 
ducing heat goes on increasing during the adult age, still, young children, and 
especially those of a feeble constitution, will suffer discomfort, and have their 
health impaired by a degree of cold that would be tolerated with impunity by 
those who are older and more robust. 

" According to Drs. Milne Edwards, and Villerme of Paris, and Dr. Trevisano 
of Castel Franco, in Italy — and the accuracy of these gentlemen's statements is 
fully confirmed by Drs. Lombard of Geneva, and Quetelet of Brussels, and by 
subsequent observers — the greatest mortality among children, from birth to the 
age of three months, occurs during the season of greatest cold, and, conse- 
quently, we find that the mortality among children is greater in northern than 
in southern climates ; and in the northern climates during winter, than during 
the other seasons of the year. Allowance, however, must be made for particular 
local circumstances, or the occasional visitation of epidemic diseases : thus, in 
most of our large cities, in the Middle and Southern States, the excessive heat 
of the summer, when conjoined with causes which prevent free ventilation, and 
tend otherwise to diminish the purity of the air, produces annually a very great 
mortality among children under two years of age ; rendering with us the season 
of greatest warmth far more fatal to infants than even that of the greatest cold.'' 

The entire chapter on the Hygienic Management of Children is well worthy 
the most careful perusal. 

One of the diseases of children less frequently observed is peritonitis. It is a 
disease, however, extremely fatal in its nature, and should be carefully studied. 
How much prolonged suffering is occasioned, and how many lives are lost, from 
an imperfect acquaintance with diseases of an obscure character, and as a con- 
sequence of that ignorance, inattention to their earliest symptoms ! How fre- 
quently has an endocarditis passed unobserved, until too late, the patient pre- 
senting no rational signs of its existence ! How often has inflammation of 
an intestine, obscure in its origin, been permitted to go on, until perforation 

r 

r 



1850.] Condie^s Treatise on the Diseases of Children. 149 

has occurred, or a communication been established between it and some vital 
organ ! Disease often cannot be skilfully combated, without a thorough know- 
ledge of its true character. To be of the greatest service to the living, the phy- 
sician must be much with the dead. We have known peritonitis in a child to 
be mistaken for inflammation of the brain — the autopsy revealing intense inflam- 
mation of the peritoneum with effusion of pus, and inflammation also of the 
lining membrane of the bladder. 

"Peritonitis, in an acute form, is by no means a very frequent disease of chil- 
dren. It may, however, occur, as a primary affection, but is more frequently 
developed in the course of some other disease. It is indicated by tension and 
pain of the abdomen, more or less acute, and invariably increased upon press- 
ure ; restlessness, constipation, and peculiar contracted and distressed expression 
of the face. 

" The pain of the abdomen is constant, and often extremely acute, and the 
tenderness, in severe cases, is such as to cause the slightest pressure, even that 
of the clothes, or the coverings of the bed, to be insupportable. The child lies 
upon his back with his knees drawn up, and exhibits extreme restlessness ; his 
cries are often constant and acute. The abdomen is commonly tense and swol- 
len, rising in a point towards the umbilicus. The tension is sometimes per- 
fectly circumscribed, and upon palpation a painful tumour is detected, without 
any change in the colour of the skin, and presenting a dull sound upon percus- 
sion. {Rilliet and Barthez.) The bowels are usually constipated, and the skin 
dry, but seldom hot. 

" Peritoneal inflammation occurring in children requires the closest attention 
and tact on the part of the physician to distinguish it from inflammation of the 
intestinal tube with which it is often complicated. Peritonitis may be distin- 
guished from pleurisy by the absence of the physical signs of the latter ; and, 
from some paroxysms of colic, by the pain being continued, and increased upon 
pressure, while, in cases of colic, the pain is remittent, and is very generally 
diminished by pressure upon the abdomen.''' "In many cases, the peritonitis 
of children assumes a chronic form, when it constitutes, probably, one of the 
most insidious affections of early life, its real character being very often over- 
looked, and a most injudicious course of treatment pursued.''' Of chronic peri- 
tonitis, Dr. Abercrombie observes: "This insidious affection is more common 
than persons not familiar with pathological investigations are generally aware 
of. It is a disease of the utmost danger, yet often extremely obscure in its 
symptoms, and can only be treated with any prospect of success by the utmost 
attention to its very earliest indications.''' "In the treatment of this insidious 
and dangerous affection, everything depends upon endeavouring to arrest it at 
its very earliest period ; for, after it has advanced but a little way in its progress, 
it is probably irremediable.'^ "All that I can say further upon this subject is 
that I have seen cases terminate favourably in families which had formerly suf- 
fered from this affection ; and that their symptoms corresponded with those which 
had been observed in the earlier stages of the cases which had been fatal." 

The article on Epidemic Meningitis is full of interest, and is ably written. 
In France, this "disease destroyed about one-half of those attacked. In the 
United States, the mortality has been even greater. In some parts of Missouri, 
five-sixths of the patients died ; in Tennessee, three-fourths ; in Mississippi, at 
least one-half; and in Alabama, full sixty per cent." For a description of the 
symptoms, we refer to the work itself. The following is the description of the 
post-mortem appearances. 

"The lesions detected after death from epidemic meningitis are chiefly con- 
fined to the cerebro-spinal meninges. The pia mater is deeply injected with 
blood, and the large vessels and sinuses are remarkably turgid. The free sur- 
face of the arachnoid is generally dry and clammy, and in several places the 
membrane is slightly opaque. Lymph and other inflammatory effusion are 
seldom met with in the cavity of the arachnoid ; but, between the latter mem- 
brane and the pia mater, there is, in many cases, more or less serosity, either 
lactescent orturbid, yellowish, and often semi-gelatinous. In others, there are met 
with, disseminated along the course of the vessels, drops, varying in size, of a 
yellowish colour and purulent appearance. More generally, patches or bands of 



1 



150 Bihliographical Notices. [Jan. 

a consistent substance, of a yellowish or greenish colour, resembling concrete 
pus, exist beneath the arachnoid, on the upper and lateral portions of the hemi- 
spheres, but especially at the base of the brain, in the space corresponding to 
the circle of Willis ; where many of the cerebral nerves are, at their origin, im- 
bedded in it. The effusion is spread over the anfractuosities, which it rarely 
penetrates. In the spinal cavity, this puriform matter extends in bands along 
the anterior or posterior face of the medulla, and, in some instances, entirely 
envelops it, and extends often to the lowest extremity of the cauda equina, in- 
vesting each of the spinal nerves at its source. In some cases, true purulent 
collections are present. As in the cranium, so also in the vertebral canal, these 
morbid deposits are confined to the subarachnoid space. The substances of the 
brain and spinal marrow are usually free from any decided lesion. In a few 
cases, however, the brain and spinal marrow have been found implicated. In 
some, the ventricles of the brain contained inflammatory effusions, and the 
choroid plexus appeared unusually vascular; in others, more or less of the sub- 
stance of the brain and spinal marrow was found in a state of softening ; in 
others again, sero-purulent effusion was detected at the base of the brain, and 
in the theca vertebraiis ; but, in every instance, the serous membrane was 
the part essentially diseased. In a great majority of the fatal cases, in which 
great disorder of the cerebral functions was manifested, after death, the substance 
of the brain was found to be either not at all or only slightly affected. Dr. 
Ames, however, in all the cases examined by him, found, on cutting into the 
substance of the brain, besides the red points commonly present in cases of 
congestion and inflammation, an infinite number of red vessels containing some- 
times fluid, and at others coagulated, blood. These were seen, likewise, upon 
removing the membranes ramifying over the base of the brain, and the floors 
and walls of the ventricles, as well as on section of those parts. The gray and 
white matter had a pink colour, dependent on the presence of veins that were 
separately visible. Of these alterations, the cerebellum partook to a greater or 
less extent in every case. Still, there is reason to conclude that, when the brain 
or spinal marrow is found affected, it is only secondarily ; the disease having 
been propagated to the substance of the cerebro-spinal axis from its meningeal 
investments. 

"In all cases in which pus was detected on the spinal medulla, it existed also 
in the brain ; occasionally, however, it was confined entirely to the latter. M. 
Tourdes hence infers that the inflammation commences invariably in the en- 
cephalon, and extends from thence to the spinal marrow. 

" The rapidity with which suppuration may occur in cases of epidemic me- 
ningitis is somewhat surprising ; M. Leonard, of Toulon, reports an instance in 
which the disease ran its course to suppuration in fifteen hours, and cases are 
recorded by M. Broussais {Hist, des Meningites CSr6bro-Spvnales), in which sup- 
puration occurred in thirty-six and forty-eight hours. 

" Slight redness of different portions of the gastro-intestinal mucous mem- 
brane is occasionally met with in the form of patches, arborizations, or dots. In 
some instances, a diseased condition of the follicles, in others, reddening, thick- 
ening, or softening, to a greater or less extent, of portions of the mucous mem- 
brane of the stomach and ileum, are present. Dr. Ames, who describes this 
latter lesion, mentions also four autopsies in which were found enlargement, 
and in one case ulceration of the agminated and solitary glands of the lower 
portion of the ileum, with enlargement, reddening, and in one case softening, of 
the mesenteric glands. 

"These lesions of the digestive organs have seldom been observed, excepting 
in patients who survived the first few days of the attack, and consequently can 
be viewed only as the result of an accidental or secondary affection. 

"In regard to the condition of the blood in epidemic meningitis, M. Fame- 
Villars found, in the post-mortem examinations made at Versailles in 1839, the 
left cavities of the heart almost entirely empty, while those of the right side 
were filled with large fibrinous coagula, of a yellow colour, and some consist- 
ence. The same thing was observed by the physicians in other parts of France, 
especially in cases in which the blood drawn during the lifetime of the patient 
was buffj and contained but little serosity. In four analyses of the blood, pro- 

r 

■ f 

f 
{ 



1850.] Maclise's Surgical Anatomy. 151 

cured in two cases at the first venesection, in one at the second, and in another at 
the third, M. Tourdes states that the principal alteration detected was an altera- 
tion of the globules and of the fibrine, but especially of the former. Dr. Ames 
found the blood drawn from the arm and by cups to form large loose coagula, in 
which all the red globules were rarely included. The serum separated slowly, 
and in small quantity. The colour was generally light, in a few cases approach- 
ing to that of arterial blood. Of thirty cases it was buffed only in four. It pre- 
sented an excess of fibrine." 

The work of Dr. Condie is unquestionably a very able one. It is practical in its 
character, as its title imports ; but the practical precepts recommended in it are 
based, as all practice should be, upon a familiar knowledge of disease. The op- 
portunities of Dr. Condie for the practical study of the diseases of children have 
been great, and his work is a proof that they have not been thrown away. He has 
read much, but observed more ; and we think that we may safely say that the 
American student cannot find, in his own language, a better book upon the sub- 
ject of which it treats. E. H. 



Art. XIY. — Surgical Anatomy. By Joseph Maclise, Surgeon. "VYith coloured 
plates. Parti. Philadelphia. Lea & Blanchard, 1850: quarto, pp. 40, with 
sixteen plates. 

Every surgeon must have experienced, at times, the want of a correct visible 
representation of the human frame, or of some particular part, wherewith to 
give distinctness to his recollections concerning them. The precise course of 
an artery ; the exact relative situation of a nerve or plexus of veins ; the disposition 
of a fascia — these are questions of immense practical moment, when human 
life may be lost or endangered, or the future usefulness of a limb sacrificed, by 
an ignorant surgeon, to whom the performance of an operation has been en- 
trusted. All surgeons are not, unfortunately, good anatomists, and even those 
who are, often feel the necessity of referring to a surer guide than memory, 
when a delicate operation is pending. The oft-quoted lines of Horace — 

" Segnius irritant animos demissa per aurem, 
Quam quae sunt ocuiis subjecta fidelibus" — 

apply with remarkable force and truth to this subject. There are few who 
have the realities of Regional Anatomy so accurately and vividly impressed 
upon their minds as to be able, by a subjective act of the will, to transfer the 
picture to the eye. Verbal descriptions, knowledge acquired from written 
histories, are less trustworthy than actual vision. The most experienced navi- 
gator may lose his ship, if he trusts to his recollection alone, to enable him to 
distinguish the true from the fancied light, instead of studying his position 
upon official charts. The surgeon's chart is the dead body; but this he cannot 
always consult, even in a city abounding in almshouses and dissecting-rooms ; 
much less can he, when remote from these facilities. Under such circumstances, 
the only reliable substitute is a carefully prepared drawing of the part which 
he wishes to study. 

There are many publications extant, which embody excellent illustrations of 
surgical anatomy, as those of Bourgery, Blandin, and Tuson ; but most of these 
are, if possible, too elaborate, and all are so expensive as to be beyond the ac- 
''V.»^quisition of most surgeons. The work of Mr. Maclise obviates, we think, both 
of these objections, combining great truth and beauty of illustration with 
cheapness. When completed, the book will contain about one hundred and 
fifty double-columned pages, of imperial quarto dimensions, and from fifty to 
sixty plates, superior in execution to any that have ever been issued in this 
country, certainly. The American reprint of the first part of the work is a 
strikingly faithful copy of the original. The remaining three parts will be issued 
as speedily as practicable. The price of the completed volume is fixed at only 
eight dollars. 

The first and second plates, and the commentary which accompanies them, are 



152 BihliograpMcal Notices. [Jan. 

devoted to a consideration of *' The form of the thoracic cavity, and the posi- 
tion of the lungs, heart, and larger blood-vessels/^ 

The author dwells upon the fact, that the thorax is improperly termed **a 
cavity f^ that its contents completely fill it at all times, but that, in consequence 
of the alternate systole and diastole of its parietes, and of the varying attitude 
of the diaphragm, as influenced by the abdominal muscles and organs, the situ- 
ation of the thoracic viscera, and the diameters of the chest, are subject to vari- 
ations. These considerations are made to have a practical bearing by illustra- 
tions drawn from the effect of wounds inflicted upon different points of the 
walls of the chest. Thus, the apex of the lung is shown to project into the 
root of the neck, above the level of the sternal end of the clavicle, particularly 
when the lung is inflated, or when it is forced to seek accommodation for itself 
above, in consequence of "the stays or girdle which brace the loins of most 
women, preventing the expansion of the thoracic apparatus, naturally attained 
by the descent of the diaphragm." He mentions, also, an interesting fact in 
philosophical anatomy, "that, at those very localities, viz., the neck and the 
loins, where the lungs by their own natural effort are prone to extend them- 
selves in forced inspirations," happen the " anomalous creations of cervical and 
lumbar ribs," to protect these important organs at these points of acquired ex- 
posure. 

We must " enter a caveaf against the author's opinion that "it is very pro- 
bable that the continuous murmur which we hear through the stethoscope, in 
chlorotic females, is caused by the pulsation of the subclavian artery against 
the top of the lung," p. 10. Hope has clearly shown that this murmur is gene- 
rated in the veins about the root of the neck, and not in the arteries. [Dis- 
eases of Heart, &c.. Am. ed., p. 136, &c.) But, undoubtedly, the situation of 
the subclavian artery, at this point, enables the auscultator to arrive more surely 
at the knowledge of the particular valve of the left ventricle which is the seat 
of a morbid sound, since the walls of the artery furnish a direct and a good 
medium for the transmission of sound from the heart. 

These two plates likewise exhibit very good views of the neck ; the first, of 
its lateral region ; the second, of its anterior face ; but these are rather inci- 
dental. 

The next succeeding eiglit plates, and the associated text, illustrate dissections, 
both superficial and deep, of the neck and face. The usual division of the 
cervical region into triangular spaces is adopted by the author, and the contents 
of each are well exhibited. The situation of each important vessel and nerve, 
at different points of its course, is carefully pointed out, and the sources of acci- 
dent or difficulty which may occur in operating upon, or near them, are noted 
in connection with each. Mr. Maclise insists upon the expediency of indi- 
cating the situation and direction of the blood-vessels, by referring to j9om^5 on 
the skeleton, whenever this can be done, rather than to muscular lines, because 
the latter are liable to constant change with every motion of the part to which 
they belong, and are diverted by the pressure of tumours, &c. Moreover, the 
muscles vary very much in dimensions. On the contrary, the lines of the 
bones, and the position of the bony prominences, are subject to less variation, 
and hence are surer guides. The relational anatomy of the carotid and sub- 
clavian arteries receives, as the importance of the subject demands, a very 
satisfactory share of the author's attention. 

One chapter and two plates are devoted to the elucidation of " the sterno- 
clavicular or tracheal region, and the relative position of its main blood-vessels, 
nerves," &c. In these, the anatomical peculiarities of the innominata, and of 
the subclavian and carotid arteries at their origin, are described. The existence 
of the arteria innominata is a very remarkable peculiarity, a departure from 
the ordinary law that the median line of the body is the line of fusion of its 
two originally distinct halves, and that " all structures ororgans which range 
this common centre-line are either symmetrically azygos, or symmetrically 
duplex," p. 25. This law is operative as regards the skeleton; we find that 
the occipital, parietal, frontal, nasal, maxillary, sphenoid, and palatal bones, the 
vomer, the os hyoides, the bones composing the vertebral column and the walls 
of the chest, and those forming the pelvis, offer no exception to this law of 



r 



1850.] Maclise^s Surgical Anatomy. 153 

symmetry. The same general plan Is observed in the disposition of the organs 
of the body ; the brain ; the organs concerned in mastication ; the pharynx and 
oesophagus ; the larynx and trachea; the lungs, the thyroid body, the heart in 
one sense ; the liver in foetal life ; the kidneys, the pelvic organs and their ex- 
ternal appendages ; all these display the same harmonious idea. But, in the 
case of the vascular system, this symmetry is departed from, by the creation 
of the innominate artery. Yet even here, nature sometimes reverts to her 
favourite law by dispensing with the innominata entirely, and allowing the 
subclavian and carotid arteries of the right side to spring directly from the 
arch of the aorta, as do their congeners of the left side ; or by evolving the 
latter from one trunk, thereby forming a left innominata. On the other hand, 
as if to show that formative energy is not to be trammelled by the laws of the 
schools, still wider departures are made in the origin of these important vessels, 
all springing at separate points from the arch, altogether to the right side of the 
median line ; or, again, the left carotid sometimes rises from the innominata, &c. 
&c. (Quain and Sharpey). These and similar anormalities concerning these 
vessels are mentioned by Mr. Maclise, and suitable cautions are impressed 
upon the reader who may propose to operate upon them. The dangers belong- 
ing to tracheotomy and laryngotomy, and the means of overcoming them, are 
also well described. 

Plates 11 and 12, exhibiting "the surgical dissection of the axillary and 
brachial regions, displaying the relative order of their contained parts,'' are 
exceedingly beautiful specimens of art, as well as faithful copies of nature; 
so faithful that they will terrify, we should fancy, any one from invading such 
a solemn labyrinth of arteries, veins, nerves, and lymphatics, without due pre- 
paration, without careful examination of his good blade, and much spiritual 
fortification by texts and studious vigils. 

The author's comments do not underrate the diiEculties in the way of opera- 
tions implicating the axillary space, and convey judicious suggestions and in- 
formation concerning its anatomical peculiarities. 

In the following chapter, and the accompanying figures, 13 and 14, the same 
subject is continued, with particular reference to the differences between the 
male Siud female axilla. Of course, the main features of this region are the 
same in both sexes, as regards the disposition of important organs. But the 
existence of the mammary gland in the female, resting as it does upon the 
pectoralis major muscle, and overhanging the axillary margin of the latter, 
must of necessity create a difference in the configuration and in the dimensions 
of the axilla of the female, as compared with that of the male. The shape of 
this cavity, if it may be so called, is conical, the base presenting externally ; 
but its depth and its lateral measurements are subject to great fluctuations, 
according to the positions and motions of the arm. These same variations 
will affect the relative situations of the blood-vessels and nerves of the axilla, 
so much so as materially to influence the degree of accessibility of these organs. 
These facts are illustrated by the figures, and commented on in the text. 

The lymphatic bodies of the axilla are well shown, and the connection of 
these with the important operation for the removal of the mammee is promi- 
nently noticed. The implication of the lymphatic glands at the root of the 
neck is not so much adverted to by writers generally, when treating of diseases 
of the female breast, as the importance of the fact demands. Mr. Maclise 
alludes to it. If the disease of the gland be on the sternal side of the nipple, 
,^,. the lymphatic bodies at the root of the neck, laterally, will be found enlarged, 
^^•as often perhaps as those in the axilla ; and the signification of this condition, 
touching the question of amputation, will be the same in both cases. 

The author indicates clearly the course of the vessels and nerves, from the 
axilla downwards, along the arm, their position with reference to the muscles 
and bony prominences, and the most common accidents and structural diseases 
which are liable to implicate this surgical region. Some judicious observations 
are also made concerning the application and adaptation of surgical apparatus 
to this and other parts of the body. 

The concluding chapter of this first part of the work, and the last two plates, 
are devoted to the anatomy of "the bend of the elbow and the four-arm, show- 



154 Bibliographical JS^otices. [Jan. 

ing the relative position of the arteries, veins, nerves, ^^ &c. We have expressed 
great satisfaction at the execution of the preceding dravrings, and we extend 
the same meed of commendation to these ; they are very beautiful and life-like. 
In his comments upon the surgical region w^hich these figures portray, Mr. 
Maclise displays the same anatomical knowledge, and the same good judgment 
in the application of it, that he has elsewhere evinced. The anatomy of this 
region is not so intricate as that of the neck or of the axilla ; but it does not, 
therefore, form a less important subject for study, because accidents calling for 
surgical aid are of very frequent occurrence here, more so than in the other 
parts named. The veins concerned in phlebotomy, and the accidents attending 
this operation, as well as the mode of performing the operation itself, are duly 
described. The subjacent structures are clearly unfolded in the 16th plate, 
and their relations to each other are explained. The author dwells at length 
on the points at which the different arteries of the superior extremity may be 
most conveniently tied, and the best methods of reaching them. Thus endeth 
the first part. 

In conclusion, we feel bound to express our thanks to Mr. Maclise for his 
very excellent and instructive book ; and to the American publishers, for the 
Qpportunity of studying and of possessing it. F. W. S. 



Art. XV. — On the Diseases of Infants and Children. By Fleetwood Church- 
ill, M.D., M.K. I. A., Hon. Member of the College of Physicians of Ireland, 
Hon. Member of the Philadelphia Medical Society, &c. &c. Author of the 
"Theory and Practice of Midwifery,^' "On the Diseases of Females," &c. &c. 
Philadelphia, Lea & Blanchard, 1850 : pp. 636, 8vo. 

We hail with much pleasure this volume, as completing the valuable series of 
works — comprising Midwifery, and the Diseases of Women and of Children — 
by the same author. For the completion of the series, it appears that we are 
indebted to the American publishers. 

The author, in his preface, states : " It is with much gratification that I 
acknowledge the volume to owe its existence to the solicitations of my excellent 
American publishers. After making a considerable collection of works on 
diseases of children, I had laid them aside, hopeless of accomplishing the task 
of v.a-iting the work I had contemplated, but it was impossible to decline an 
invitation so flattering from a country which had shown so much indulgence to 
my former works. I have, therefore, in such leisure as I have been able to com- 
mand during the last three years, written this volume, not as an exponent of 
my own experience alone, but as embracing the information recorded by all the 
authors within my reach, of which I have freely availed myself; and if it prove 
useful and acceptable to my American brethren, I shall be richly repaid." 

The present volume will sustain the repvitation acquired by the author from 
his previous works. The reader will find in it full and judicious directions for 
the management of infants at birth, and a compendious, but clear, account of 
the diseases to which children are liable, and the most successful mode of treat- 
ing them. 

The diseases of children have, within a recent period, attracted much careful 
and studious attention, and this they fully merit. Independently of their obscur- 
ity, which, of itself, excites in the mind a disposition to master and remove 
them if possible, the helpless condition of the sufferer has strong claims upon 
the feelings of the conscientious and considerate practitioner. 

Dr. Churchill's book is divided into two parts: the first of which is devoted 
to Preliminary Observations, the Management of the Infant at Birth, the Food 
of Infancy and Childhood, Cleanliness, Air, and Exercise. 

The second partis divided into seven sections, embracing the various diseases 
to which children are subject. These are arranged under the following heads : 
Diseases of the Cerebro-Spinal System, Diseases of the Respiratory System, 
Diseases of the Skin, Eruptive Fevers, Infantile Remittent Fever, Worm Fever, 
and Gastric Fever. 



r 



1850.] Churchill on the Diseases of In/ants and Children. 155 

Under the head of Preliminary Observations, the author remarks; **A very 
limited acquaintance with statistics, or even a moderate experience, is quite suf- 
ficient to convince us of the high degree of mortality which prevails among in- 
fants and children ; literally, they spring up and are cut down like flowers of 
the field. This mortality commences before the birth of the infant ; from various 
causes no inconsiderable proportion of those ushered into the world are still- 
born. M. Quetelet, in his very learned and able work, thus states that, in the 
principal cities of Europe, the mean proportion of still-born children is one in 
every twenty-two births, and the number is three times greater among illegiti- 
mate than among legitimate children. 

" The same author gives a carefully compiled table of the different ages in 
Belgium, which shows that, of the infants born alive, one-tenth died within a 
month, a mortality equal to that between the ages of seven and twenty-four 
years. By the fifth year, nearly one-half the number of children had died. 

" In Prussia, during the interval from 1820 to 1828, the deaths in the first 
year were in the ratio of 26,944 to 100,000. In France, in 1802, it amounted to 
21,457 ; in Amsterdam, to 22,735 from 1818 to 1829 ; in Sweden, to 22,453, from 
1821 to 1825. 

"From the first report of the Kegistrar-General of England, it appears that 
more than one-third of the total deaths in England and Wales occur under two 
years of age ; the proportion being 42.54 per 1000 of the deaths registered, and 
two out of every 7iine infants entering life die within the first year." "Assuming 
seventy years as the natural term of life, we may form some faint conception, 
from the preceding facts, how many elements of destruction must still be in full 
activity, when, as in the case of England, one-third of the race is cut off within 
the first two years of existence." In Mr. McClean's visit to St. Kilda, he states 
that ^^ eight out of every ten children die between the eighth and twelfth days of 
their existence ;" and this, he conceives, is mainly owing to the "filth in which 
they live, and the noxious effluvia of their houses." 

But there are more shocking evidences still of the result of bad accommoda- 
tion and mismanagement. For example. Dr. Combe states that, "about a cen- 
tury ago, the workhouses in London presented the astounding result of twenty- 
three deaths in every twenty-four infants under the age of one year. For a long 
time this frightful devastation was allowed to go on, as beyond the reach of 
human remedy. But when at last an improved system of management was 
adopted, in consequence of a parliamentary inquiry having taken place, the 
proportion of deaths was speedily reduced from 2600 to 450 a year." 

Facts like the above show the great importance of attention to hygienic mea- 
sures for the prevention of disease, and we hope the period is not far distant 
when there may be found among our legislators those who will feel it their 
duty to devote proper attention to the health of our large cities. In a repub- 
lican country especially, where, as in other places, the daily avocations of the 
poor are of such a nature as to occupy nearly all their thoughts, it is the duty 
of those who are more enlightened, and who have more leisure to provide for 
their welfare in this respect. 

The following observations, under the head of Air and Exercise, contain much 
truth, and are well expressed : — 

"Up to a certain period, girls and boys share their plays and exercise and 
walks together, aad it is far better that the former should be allowed as much 
liberty as the latter, than that they should be prematurely confined. The time, 
however, will come when the association of brothers and sisters will to a great 
^V-r degree be broken. Boys, however, will obtain sufficient air and exercise for 
themselves, and even the madness of parents for the precocious advancement of 
their sons will hardly obstruct this. Any one who is so deluded as to force for- 
ward the intellect of his son, should remember that he can only do so at the ex- 
pense of health, that the deprivation of adequate air, exercise, and play will be 
followed by a delicate, enfeebled manhood, and probably by a premature death. 

" But little girls arc more frequently victimized. From the moment of her 
separation from the sports of childhood, the great object is to make a little wo- 
man of her. Her mind is crammed and confused with a little of every kind of 
knoicledye, and her body cramped and confined by stays, and the endeavor to 



\ 



156 Biblwgraphix^al Notices. [Jan. 

maintain a womanly carriage ; and her feet are cased in tight shoes, so that the 
pleasure of free movement is not only forbidden, but destroyed. And the result 
is not grace, but formality — grace cannot exist without freedom, and the tutored 
effort to be graceful, or ladylike, is necessarily destructive of success. 

"Little girls, as they grow up, may very properly be restrained from boister- 
ous play, but at the same time free air and exercise should be secured for them 
without the inconvenience of tight dress. A brisk walk, a race after a hoop, or 
a canter on a pony, will give bloom to the cheek and brightness to the eyes ; 
and the structure of the body being well developed and allowed free play, easy 
and natural grace will be the consequence.^' 

Under the head of Medicine, the following remarks occur : — 

" Very few words will comprise all I have to say in this matter, because I think 
that the less medicine a child takes, the better for his health; so long as the 
child is in health, the natural functions will be performed, according to his con- 
stitution, without medicine, and if a child be sick, the less tampering with medi- 
cines by mother or nurse, the better.^' 

How fortunate would it be for children, if all parents were influenced by such 
considerations ! One remarkable feature in the work before us is, that it does 
not appear to be designed for introduction into families. We observe no trans- 
lations of technical words or other means of rendering the work a vade mecum 
for mothers in the dosing of their infants. Books of this kind are productive of 
incalculable mischief. 

In treating of Trismus Nascentium, or nine days fits, the author observes : — 

"A more intractable disease does not come within our observation. Dr. Col- 
lins remarks, 'With respect to the treatment, I have nothing to propose, as I 
have never seen an instance where the child seemed even temporarily relieved 
by the measures adopted." 

No mention is made of the observations of Dr. J. Marion Sims upon this sub- 
ject, the last of whose papers appeared in this Journal for Oct. 1848. 

In the chapter on Acute Meningitis, including Tubercular Meningitis as one 
of its fo7'ms, the author observes: " Modern writers, indeed, particularly the 
French, have drawn a marked distinction between acute meningitis and tuber- 
cular meningitis, but, as the most intelligent of them confess that they differ only 
in the pathological condition of the membranes, and not essentially in the symp- 
toms or course of the disease, I have thought it better to include both under the 
one name, and to describe them as two (out of many) phases of the same dis- 
ease." We regard this arrangement as unfortunate, for simple and tubercular 
meningitis do differ materially as respects their symptoms and course ; besides, 
one is a disease curable by prompt and energetic measures, and the other is 
incurable: hence it is of great importance to study each with the utmost care, 
so as to be able to make a correct diagnosis. For an excellent paper upon 
the differential signs of the two diseases, we refer the reader to a paper by M. 
Rilliet in the Provincial Medical and Surgical Journal for 1847.'^ 

One of the best written chapters in the book appears to us to be that on Croup. 

This disease "is one of the most alarming and fatal to which children are lia- 
ble ; sudden in its attack, alarming in its symptoms, and rapid in its results, it 
sweeps over a family, leaving behind it distress and desolation. No matter 
how slight the attack may be, the most vigilant care is requisite, as the disease 
very often acquires great intensity in a very sudden manner, and a few hours 
lost can never be regained. 

"Or, if the treatment be early, active and judicious, the disease may be 
checked in either the first or second stages, and we shall then find that the cha- 
racter of the cough will be changed ; it becomes softer and more moist ; the 
respiration, although for a time rough, is much easier and less humid, and the 
voice acquires some tone ; the case assumes the aspect of common catarrh with 
hoarseness. I have seen this change take place in my own children in two 
hours, when the disease was attacked in the very commencement. In more 
severe cases, the fever with evening exacerbations may continue for some time 

* [See also the first article in the Original Department of this No. — Editor.] 

f 



1850.] Stanley's Treatise on Diseases of the Bones. 157 

after the voice, cough, and breathing have lost all croupy character, as in a case 
at present under my care. 

" We must never forget the great liability of the disease to relapse, nor cease 
our watchful care until the patient has perfectly recovered. It is also very apt 
to recur in the same individual. According to Julien and Albers, it has been 
known to recur seven and nine times. I have seen it occur two, three, or four 
times. Nor can we be sure that every attack will be equally mild ; a child may 
recover from two or three attacks, and be destroyed by the next. Much of the 
chance of recovery depends upon our seeing the disease at its commencement; 
for even the milder cases, if neglected, may assume greater intensity, and de- 
stroy the patient.'^ Too much vigilance cannot be exercised in cases of croup. 

The article on Cholera Infantum is not so satisfactory as could be desired, 
either as regards its pathology or its treatment. In the description of its patho- 
logy, it is incorrectly stated that the liver is generally greatly enlarged. We are 
persuaded that much of the mortality from cholera infantum is attributable 
to the purgative and perturbating plan of treatment so long adopted. That 
the fatality of this disease is very great, all admit. The disease is essentially 
an inflammatory one, attended, it is true, with symptoms of a typhoid character, 
but demanding antiphlogistic treatment. In some cases bleeding, in all when 
the disease has passed into the second stage, the local application of cups or 
leeches to the abdomen, are required, and often demand repetition, with such 
internal remedies as tend to allay irritation and promote healthy secretions. 
Were this plan more generally adopted, with proper attention to hygienic mea- 
sures for the prevention and cure of the disease we are persuaded the mortality 
would be greatly diminished. A large proportion, by far the greater number, of 
cases occur in houses situated in ill-ventilated courts and alleys, to which the 
light has but partial access, but in which the heat in our summer months is most 
intense. The erection of such buildings should be prohibited, or be at least 
under the control of a sanitary committee who should see that the health of the 
inmates is properly attended to. 

The diseases of the respiratory organs, gangrene of the mouth, measles, scar- 
let fever, and small-pox appear to be treated in a full and satisfactory manner. 
We must not close this notice without calling attention to the author's style, 
which is perspicuous and polished to a degree, we regret to say, not generally 
characteristic of medical works. We recommend the work of Dr. Churchill 
most cordially both to students and practitioners as a valuable and reliable 
guide in the treatment of the diseases of children. E. H. 



Art. XVI. — A Treatise on Diseases of the Bones. By Edward Stanley, F. R. S., 
President of the Royal College of Surgeons of England, and Surgeon to St. 
Bartholomew's Hospital. Philadelphia, Lea & Blanchard, 1849 : 8vo. pp. 
286. 

It is scarcely necessary to remind those who have paid any attention to spe- 
cial pathology, or who are at all acquainted with its history, that Mr. Stanley's 
name is intimately and inseparably associated with investigations of the dis- 
eases and accidents to which the osseous system is liable ; for there is hardly 
a work of repute in either hepiisphere, in Great Britain or on the Continent, 
which describes the morbid processes and injuries affecting the bones, which 
does not make frequent reference to this gentleman, and evince great respect 
for his labours and his opinions in this department of our science. His long 
connection with St. Bartholomew's Hospital, and his high position in London, 
have afforded him ample opportunities for studying these subjects, both in tho 
living and on the dead. 

The volumes of the Medico- Chirurgical Transactions nxe the chief repertory 

in which, until now, the results of Mr. Stanley's investigations and experience 

have been recorded. It was, therefore, with great pleasure that we noticed 

the publication, in England, of a separate volume, which renders these results, 

No. XXXViL— January, 1850. 11 



158 Bibliographical Notices. [Jan. 

as regards the "Diseases of the Bones/^ more accessible to the profession at 
large. This volume is accompanied by a series of plates, beautifully illustra- 
tive " of the eifects of disease and injury of the bones," concerning which the 
author observes : " The volume of illustrations contains, with the descriptions 
of the plates, full explanations of the subjects to which they relate, so that, 
in respect to these subjects, it is a complete and independent work." The 
former of these volumes is now reprinted in this city, as announced above, and 
is presented to the profession. 

An adequate review of Mr. Stanley's book would justly demand more space 
than is consistent with our present limits. We can, therefore, only call atten- 
tion to the contents of the volume. " The size of the volume bears no propor- 
tion to the number of facts out of which it is constructed. For in this, as in 
other scientific investigations, the first object has been to obtain the facts, 
and the second to interpret them rightly for the conclusions they warrant." 
—Preface. 

In the introductory chapter, Mr. Stanley throws out a few general remarks 
with regard to the vital peculiarities of bone, and the modifications which 
these peculiarities impress upon the morbid processes to which the osseous 
system is prone. 

The volume comprises /owrj^ar;!*. In ihejirst, are considered the subjects of 
hypertrophy, atrophy, neuralgia, inflammation, suppuration, caries, ulceration, 
and necrosis of bone. — pp. 25-123. It will scarcely be doubted that the remarks 
on these subjects — the fruits of talent and study such as Mr. Stanley has 
brought to bear upon them — contain something more than is generally known 
concerning them. This will be found to be particularly true with regard to 
the author's observations on h3^pertrophy, neuralgia, inflammation, and necro- 
sis. We believe that he is the first who has called attention to the effect of 
increased nutrition upon the length of bones which are shown to undergo an 
augmentation in this, as well as in the other dimensions. The chapter on 
necrosis is long, and full of interest ; and we are glad to find that, while the 
author describes fully all that is known respecting the pathological changes 
which occur in the progress of the death and reparation of the bones, he makes 
this knowledge conduce to the determination of the mode of treatment best 
adapted to this disease. Thus, surgery becomes a science, not a mere mechan- 
ical handicraft. 

" Tumours ofhone^' form the subject of study in the second part. — pp. 125-177. 

The author first enumerates the principal products found in the tumours of 
bone, and then presents a history of individual tumours, based upon their 
peculiarities of structure and composition. We have here described the carti- 
laginous tumour of bone (osteo-sarcoma) ; the osseous (exostosis; and the ma- 
lignant osteoid tumour, first described by Mliller) ; the tumour composed of 
brain-like matter (fungus medullaris, of Muller) ; the fibrous tumour ; the tu- 
mour composed chiefly of soft, gelatinous substance, analogous to the gelatini- 
form cancer of other tissues ; the fatty tumour; the erectile tumour; the blood- 
tumour of bone, in which the blood is enclosed in a cyst constituted either of 
osseous tissue and periosteum, or of periosteum and the surrounding struc- 
tures ; the entozoary tumour ; the membranous cyst of bone. A section is em- 
braced in this part of the volume, containing "General considerations relative 
to the diagnosis and progress of the tumours of bone." The object of these 
remarks is to lay down the broad distinctions which exist between the innocent 
and the malignant tumours of bone, and to consider the circumstances con- 
nected with the nature and relations of the particular tumour, which relate to 
the mode of effecting its removal, when this seems expedient. 

A very valuable portion of this division of the book is that which is devoted 
to the description of pulsating tumours of bono, the sources of their pulsation, 
the diagnosis between them and aneurism, and their treatment. 

The third part comprises the observations on rickets, mollities, and fragilitas 
ossium, scrofula in bone, and hard carcinoma and melanosis in bone. — pp. 179- 
209. These are all subjects of great interest, not only for the consequences 
which they involve to the individuals suffering from them, but to the patholo- 
gist for the curious and complex changes to which they give rise, or from 



< 



^ 



1850.] Stanley's Treatise on Diseases of the Bones. 159 

which they proceed. Mr. Stanley gives a lucid sketch of the various steps 
through which healthy bone passes, until the complete establishment of that 
complex condition to which the term "rickets^' has been attached; and then 
exhibits the effects of this condition upon individual bones, and portions of the 
skeleton. 

He considers the affections usually called mollities, and fragilitas ossium, not 
as distinct diseases, but as conditions of the osseous structure, produced by a 
variety of causes, affecting the whole system as well as the bones, or confined 
to the latter, and even limited in their action to particular bones. 

The author dissents from the generally received belief, that scrofulous dis- 
eases of the joints originate, for the most part, in a similar disease of the bones 
which form them. He thinks that this is true in only a proportion of cases. 
The appearances of the bones in which scrofulosis is occurring, and the changes 
subsequent to tuberculous deposition, are narrated by Mr. Stanley, and a brief 
consideration of the possibility of cure in the different stages of scrofulous dis- 
ease of bone is entered into. 

Part fourth is allotted to the "morbid growths from the jaAvs ; diseases of 
the bones of the spine;'' and "diseases of periosteum" — in separate chapters, 
—pp. 211-286. 

Under the first of these divisions, are comprised epulis, and epithelial cancer, 
and the treatment by operation and other means which they require : and 
tumours of various kinds which are connected with the inferior maxilla. With 
reference to the latter affections, the author remarks: "It is doubtful whether 
all the morbid growths stated to arise from the outer surface of the jaw, have 
not been instances of epulis, or epithelial cancer, originating in the gum, or 
mucous membrane adjacent to it, and, in their progress, acquiring attachment 
to the bone.^' After discussing the character of these aberrations of nutrition, 
and the dangers and difficulties to which they give rise, a portion of the chap- 
ter is devoted to the operations practiced upon the lower jaw. A similar ex- 
amination of the " morbid growths from the upper jaw,'' involving the diseases 
of the antrum, together with the operative proceedings instituted for their 
relief, terminates this chapter. 

In the second chapter, the diseases of the spine are treated of, including, not 
only those of the bones, but of their connections and appendages — fibro-carti- 
lages, ligaments, and periosteum. " Some of the diseases of the spine are of 
an inflammatory nature, simple or rheumatic : others are of a scrofulous cha- 
racter, and combined with the deposition of tubercles in the bones and fibro- 
cartilages. These also occur in the spine, the malignant diseases carcinoma, 
encephaloma, melanosis.'^ Each of these morbid processes receives a full share 
of the author's attention ; as to their pathological character, the derangements 
of function and of structure which they engender, the degree of importance 
which properly attaches to the most prominent symptoms, and the treatment 
most appropriate to them. Among the most important of these diseased con- 
ditions are psoas and iliac abscesses, and the distortions of the spine, which 
result from diseases of various kinds affecting its component anatomical parts. 
These, as well as others, are dwelt upon as fully as their importance demands ; 
and the author's observations upon their treatment are conceived in a very 
philosophical and rational spirit. 

The volume ends with a chapter on "diseases of periosteum.^^ The remarks 
on these subjects are comprised in two sections: inflammation of periosteum, 
and malignant disease of this membrane. 

In concluding this necessarily too brief survey of Mr. Stanley's book, we 
cannot but express our conviction that an attentive perusal of it will afford 
pleasure and profit to all. It is a volume which requires study. It has one 
prominent feature which we have not alluded to, but which renders it pecu- 
liarly well adapted for practical reference, as well as for closet meditation : it 
•abounds with briefly, but carefully recorded cases, exemplifying almost all the 
diseases of which the author treats. F. W. S. 



^ 



160 Bihliograpliical Notices. [JaD, 



Art. XVII. — Principles of Human Physiology, with their Chief Application to 
Pathology, Hygiene, and Forensic Medicine. By William B. Carpenter, 
M. D., F .R. S., F, G. S. ; Examiner in Physiology in the University of London ; 
Corresponding Member of the American Philosophical Society, and of the 
National Institute of the United States ; Lecturer on Physiology at the Lon- 
don Hospital Medical School. Fourth American edition, with extensive ad- 
ditions and improvements by the Author. With two plates, and three hun- 
dred and four woodcuts. Philadelphia, Lea & Blanchard, 1850 : 8vo. pp. 
750. 

We have already noticed, in terms of high commendation, the previous edi- 
tions of Dr. Carpenter's *' Principles of Human Physiology.'^ Their peculiar 
adaptation for the use of the student consists in their presenting a sufficiently 
concise and, at the same time, complete and perspicuous view of the present 
state of our knowledge in this important branch of science — with the leading 
opinions of the best authorities in reference to those points which are still in 
dispute; the application of the principles laid down to pathology, hygiene, 
and forensic medicine being at the same time carefully pointed out. 

In the present edition, which has been prepared expressly for the American 
publishers, every portion of the work bears evidence of having undergone a 
careful revision, rendering it a very full exposition of the author's latest views, 
together with the results of the recent labours of other inquirers on numerous 
points of interest in connection with the physiology of man. 

The portions of the work devoted to the consideration of the nervous system, 
and that which treats of generation, have been, in a great measure, re-written. 
The author has relinquished some of the peculiar views of Dr. Marshall Hall 
in relation to the constitution of the cerebro-spinal centres, and substituted, in 
their stead, a modification of those of Todd and Bowman. In reference to the 
interesting subject of generation. Dr. Carpenter, in the present edition of his 
work, has adopted the views of Bischofi", as to the development of the ovum ; 
being satisfied that those of Barry, presented in the last edition, are no longer 
tenable. The views now presented are admitted to be imperfect in many im- 
portant particulars, but still they are considered more accurate than those Dr. 
C. had previously advocated. 

In addition to the above, the more important additions and changes, in the 
edition before us, will be met with in the chapters on the primary tissues, and on 
nutrition ; still, every portion of the work bears the marks of careful revision, 
and every new advance the science of physiology has made since the publica- 
tion of the last edition, has been faithfully incorporated in the present. 

While several of the least important of the woodcuts previously given have 
been omitted, their place has been supplied by an increased number, and of 
superior accuracy and execution ; the subjects of nearly all of which are new. 
Few treatises on physiology now present a more full and perfect illustration, 
in this manner, of the text ; a feature, the importance of which, the student of 
former years can alone fully appreciate. 

In rising from a study of the physiology of man, as presented in the work 
before us, no one, we are persuaded, will be disappointed in consequence of 
the obscurity or paucity of the information it imparts in reference to any one 
of the important particulars which the science embraces ; nor that he is left to 
make up, as best he can, his judgment amid a confused assemblage of contra- 
dictory statements and opinions, the real value of which he has no means of 
determining. If all who consult the work are not able to assent to every con- 
clusion at which the author has arrived, they will not have to complain that 
the statement of his views is destitute of clearness and precision, or that it 
does not present a very fair and accurate outline of the present condition of 
the leading principles of human physiology. D. F. C. 



1850.] Observations on Epidemic Fevers. 161 



Art. XVIII. — Observations upon Bulam, Vomito-Negro, or Yellow Fever ; with a 
Review of a " Report upon the Diseases of the African Coast, by Sir Wil- 
liam Burnet and Dr Bryson," proving its highly contagious powers. By Sir 
William Pym, K. C.H., Inspector-General of Army Hospitals, and Superin- 
tendent-General of Quarantine. London, 1848 : 12mo. pp. 311. 

An Account of the Origin, Spread, and Decline of the Epidemic Fevers of Sierra 
Leone; with Observations on Sir William Pym^s Review of the ^'Report on the 
Climate and Diseases of the African Station.'' By Alexander Bryson, 
M.D.,R.N. London, 1849 : 12mo. pp. 174. 

Copy of a Letter of the Superintendent- Geiieral of Quarantine (Sir William 
Vjvn) to the Lords of the Privy Council, in reply to Dr. King's Report upon the 
Bod Vista Fever, said to have been introduced into the Island by the Eclaire 
Steamer. Ordered by the House of Commons to be printed. August, 1848 : 
folio, pp. 16. 

The leading object of the publication of Sir William Pym is to prove that the 
" Bulam, or vomito-negro fever" — the yellow fever of most writers — " is a dif- 
ferent disease from the bilious remitting fever; that it is not produced by, nor 
in any way connected with, marsh miasmata ; that it has not been a constant 
resident either on the coast of Africa or in the West Indies ; that it is highly 
contagious, and capable of being imported to, and propagated in, any country 
enjoying a certain degree of heat; that, like small-pox, it attacks the human frame 
but once, and attacks, in a comparatively mild form, natives of a warm climate, 
or Europeans whose constitutions have been assimilated to a warm climate by 
a residence of a certain number of years ; and, lastly, that it differs from other 
diseases, in having its contagious powers increased by heat, and totally destroyed 
by cold, or even by a free circulation of cool air." 

Mr. Pym's book contains a very large amount of materials, collected from 
different sources, bearing more or less directly upon the several points above 
enumerated — but so badly arranged, and carelessly collated, as to render it a 
very laborious task to follow him in his chain of proofs ; while it would require a 
volume, almost equal in size to his own, to analyze the evidence he has adduced, 
and place it in that light in which its real value will become apparent. 

The difference between yellow fever and bilious remittent fever ; the non- 
miasmatic origin of the first ; the necessity, for its production, of a certain 
amount of temperature ; its cessation upon the occurrence of cold or frost ; and 
the comparative immunity from its attacks of the natives of those localities to 
which it is endemic, as well as of those who have been acclimated to them, being 
facts already fully established by the investigations of the physicians of our own 
country, and very generally admitted by those of our writers and teachers who 
are, upon this subject, admitted to be among the best authorities, it is hardly 
worth while to go over the evidence which Mr. Pym has adduced, to prove these 
to be the distinctive features of yellow fever. 

The point, however, which he advances in relation to the highly contagious 
character of yellow fever, and its capability of being imported to, and propa- 
gated in, certain countries, being a disputed one — and, in opposition to which, 
the minds of perhaps a majority of the most authoritative American physi- 
cians are fully made up, and upon what they believe to be the best and 
most conclusive evidence — an examination of the facts upon which Mr. P}^! 
bases his decision, will be interesting. He has pointed, in his preface, to the 
portions of the work which he considers as most positively establishing the fact 
of the infectious nature of the fever of which he treats, and its importation into 
certain ships and communities. 

Before considering this evidence, we would remark that Mr. Pym admits that 
a continued fever of a very bad type, in which jaundice or yellowness of the 
skin is a very frequent symptom, has prevailed in the West India Islands ever 
since their discovery, and which has been denominated the seasoning fever and 
yellow fever by writers on the diseases of those islands. 

Mr. Pym thus describes the bilious remittent and the bilious continued, or 
sporadic, fevers of the West Indies, neither of which he admits is contagious. 



\ 



162 BibliograpTiical Notices. [Jan. 

" The first is an endemic of all warm climates ; it is the jungle fever of the 
East Indies, the bilious remittent of the West Indies, and the malaria or remit- 
tent of the Mediterranean, prevailing more particularly in the neighbourhood 
of marshy and uncultivated ground. 

" The second, the bilious continued, is the common fever produced by expo- 
sure to the sun, excess in drinking, and other irregularities. But, in addition 
to these two fevers, a third, the one under consideration, the Bulam or vomito- 
negro (of the Spaniards), a highly contagious disease, has, at different periods, 
made its appearance in the West Indies, in North America, and in the south 
of Spain, and supposed to have been originally imported from the coast of West 
Africa. 

" Thej^r^;^ variety of the disease, the bilious remittent, assumes such a divers- 
ity of forms and symptoms, owing to the constitution of the patient, the heat 
of the climate, and the degree of concentration of the marsh miasmata, that it 
is difficult at its commencement to draw a diagnosis between it and the two 
others ; as the disease advances, however, it shows its characteristic mark by 
remissions, and succeeding exacerbations ; and, if it proves fatal without evident 
remissions, which in its more violent form it sometimes does, on the third or 
fourth day, it is very rarely (if ever) attended with the fatal symptom peculiar 
to the Bulam fever, viz. the black vomiting.^^ 

''In the second variety, OT bilious continued fever, the headache is confined 
chiefly to the temples, the pulse is remarkably full, but not so quick as in the 
two others ; the yellowness appears very early in the eyes, and on the second 
or third day the whole body is tinged of a very deep yelloiv; it is not attended with 
the same degree of irritability of stomach as in the first and third varieties ; 
it has no remission or exacerbation, but runs its course as a continued fever, in 
from five to eight, or ten days, and, when terminating fatally, is not attended 
with black vomiting. 

" In the third variety, the Bulam or vomito-negro fever, there is at the first 
attack a peculiar shining or drunken appearance in the eyes ; the headache is 
excruciating, and confined to the orbits and forehead. It has no remission, and 
in mild cases, when it terminates favourably, is rarely attended with yellowness 
of the skin, which, if it does take place, is of 2k pale lemon colour; it runs its 
course in from one to five days ; it is attended with a peculiar inflammation of 
the stomach, which, in most cases that prove fixtal, terminates in gangrene, or in 
a diseased state of the villous coat of that organ, accompanied with vomiting of 
matter resembling coffee-grounds, and a very peculiar bloated appearance of the 
countenance. In mild cases, however, of this last disease, and of which there 
are many, it is impossible to point out any symptoms distinguishing it from at- 
tacks of fever from any cause ; and even in bad cases, until the fatal symptoms 
make their appearance. I may say (excepting its prevailing epidemically) it is 
as difiicult to decide upon its real nature, as it is in the fever of small-pox before 
the appearance of the eruption," 

It is not necessary to spend any time in discussing the accuracy of this latter 
assertion. The symptoms of yellow fever are so peculiar, that almost from the 
first period of its invasion, its diagnosis can certainly not be a matter of much 
difficulty with those who are familiar with its features. 

We have long entertained the opinion that, under the denomination 3'ellow 
fever, diseases by no means identical in character have been included — the one, 
probably, a very aggravated form of the bilious continued fever of unhealthy locali- 
ties, and the other the specific disease denominated Bulam fever by many writers ; 
the one not capable of being propagated by contagion — while the other may 
be propagated in this manner. There is a possibility, however, that diseases 
which are not capable of being communicated from the sick to the well, by a 
strictly contagious miasm, may be communicated by a conveyance of a portion of 
the poisonous atmosphere by which they are engendered in the holds of ships, 
or even by the persons of those coming immediately from the infected districts, 
under particular circumstances, and even when such individuals are not 
themselves actually labouring under the disease. 

The only positive test of the contagiousness of a disease is the escape of all 
who are strictly isolated from the sick, while those who are in intercourse 






r* 



1850.] Observations on Epidemic Fevers. 163 

with the latter are generally attacked. The notion of a disease being highly 
contagious, as insisted upon by Mr. Pym in the case of yellow fever, which, at 
the same time, cannot be introduced and propagated, excepting in countries 
having a certain amount of atmospheric temperature, appears to us to be an 
absurdity. Diseases in regard to the contagiousness of which there is no dis- 
pute — small-pox, for example — are contagious under all circumstances, however 
much the virulence of their poison may be augmented by confined, crowded, and 
filthy apartments, and badly ventilated and otherwise unwholesome localities. 

The first evidence Mr. Pym offers to prove the contagious character of yel- 
low fever is that, while, during the years 1800 and 1803, the disease prevailed 
to a great extent in Spain, to the East and West of Gibraltar — a rigid quaran- 
tine being established against the disease — the garrison at the latter place con- 
tinued healthy ; whilst, in 1804, when this precautionary arrangement was discon- 
tinued, the disease prevailed there, and occasioned a considerable mortality. To 
render evidence like this conclusive, it must be shown that all places in which 
a rigid quarantine is established are by that means preserved from the occur- 
rence of the disease, A host of facts may be adduced to prove the contrary. 

The second evidence adduced by our author in proof of the contagiousness 
of yellow fever is the success of the measures he had recourse to in 1810, when 
the fever was introduced into Gibraltar from Carthagena. 

During the prevalence of yellow fever at the latter place in 1810, four transports 
from that port, all having cases of the disease on board, anchored in the Bay of 
Gibraltar, on the 19th of September. The soldiers, who had as yet escaped the 
disease, amounting to seventy-seven, were removed from the transports on 
board of two hulks. These individuals were supplied with new blankets and 
clothing, and before entering the hulks were stripped and bathed ; their old 
clothes and bedding being destro3^ed. During the course of the first ten days, 
six men were removed to the hospital ship from one hulk, and eight from the 
other, after which the disease disappeared. 

" During the time that the disease had been going on on board the transports 
in the bay, the garrison continued in perfect health until the 20th of October, 
when, in consequence [as I must suppose) of a breach of quarantine regula- 
tions, icJiich, however, could not he detected, a Minorcan family in the south dis- 
trict, belonging to the dock yard, was attacked with the disease." 

A number of cases occurring in the neighbourhood, the whole of the infected 
persons in the infected district, with their baggage, were removed, under a 
strong guard, to tents pitched outside the gates of the garrison, and the houses 
and remaining furniture thoroughly purified. 

" Within a few days after the removal of the sick, several persons (all neigh- 
bours of the first family taken ill) were declared to be infected, and removed, 
under the necessary precautions, to the neutral ground." 

On the morning of the 28th of October, two men died of the disease, in the 
Seventh Veteran Battalion, and several others were sick in the hospital. Five 
fresh cases were also reported in the barracks in the course of the day. The 
whole regiment, with the hospital establishment, were removed outside the 
garrison. 

" Very few men were reported sick after the regiment moved into quarantine. 
Three of them, however, were taken ill in the same tent. Six died from the 
disease, who were all taken ill in the same barrack room." 

" Two cases of black vomit also appeared in the hospital of the Fourth Vete- 
ran Battalion ; one of&cer of that regiment, quartered in the south district, died 
with the same symptoms; and a lady who resided in town, but who had kindly 
assisted the last-mentioned officer during his illness, fell a victim to it on the 
third day of her indisposition. Mrs. Nicholls, also, whose maid-servant was 
one of the first taken ill in the infected district, was carried off in forty-eight 
hours after being attacked by it." "The only member of the Minorcan family 
who escaped the disease (a boy), continued in health during the time of his 
quarantine, but was attacked the fifth day after his return to his habitation, 
and died with black vomiting in less than seventy hours' illness. Upon inquiry, 
it was ascertained that the inspector of the district had neglected to wash and 



164 Bibliographical Notices. [Jan. 

purify the bed which this young man slept upon, and which had been used by 
some of his family when the disease first made its appearance. 

"The proofs of contagion here are so indisputable, that it might be thought 
unnecessary to make any observations upon them ; I shall, therefore, only re- 
capitulate, in as few words as possible, that Mr. Arthur, who went on board the 
transports, and all the sailors who remained on board, caught the disease, 
while sixty-three out of sixty-seven soldiers who were removed from the focus 
of contagion, escaped it. The disease on shore commenced in the Minorcan 
family, and ran through all the members of it, seven in number. The sick 
soldiers vjJio died were all taken ill in the same barrack room. Mrs. Nicholls 
caught the disease from her servant; and within the walls of the town (a mile 
at least from the infected district), only two persons were attacked with the 
disease, viz., the lady who had assisted Captain Boyd, and a priest who attended 
the Minorcan family.'' 

Now certainl}^ the foregoing facts present no shadow of evidence that the yel- 
low fever was introduced into Gibraltar from the sick on board the transports ; 
and, even presented as they are in the strongest point of view, divested of 
many collateral circumstances essential to the settling of the question at issue, 
they cannot be received as conclusive evidence that, in any one of the cases 
alluded to, the disease was communicated by a poisonous emanation from the 
bodies of the sick. We see, in the whole course of the disease as above de- 
tailed by Mr. Pym, the evidence of its occurrence from morbific causes existing 
in a certain district of the town, and infecting those, and those only, who were 
exposed to the influence of these causes. But two cases, we are assured, oc- 
curred in individuals living out of the infected district, and both of these had 
been within that district. This localization of the yellow fever in particular 
neighbourhoods of a city is familiar to American physicians, who are accus- 
tomed to put a stop to the disease by removing the inhabitants, sick and well, 
from the infected district, and permitting no one to enter it until after the oc- 
currence of frost — a plan which would be calculated rather to spread than to 
arrest an actually contagious disease. 

We shall onl}^ present one or two more of the facts that are especially referred 
to by Mr. Pym as evidence of the contagiousness of yellow fever. 

The Bann sloop-of-war arrived at the Island of Ascension, with the yellow 
fever on board, on the 25th of April, 1823. At this time, the garrison on shore 
were healthy, but the Bann had already buried thirty-two men. All intercourse 
between the former and the sick tents of the latter was forbidden. 

" In a short time, however, fever made its appearance among the garrison on 
shore, in the family of a soldier's wife, who had been washing for one of the 
Bann. It first seized a hoy, then the woman herself, and, in a few days, four 
men belonging to the garrison were attacked. Of the crew of the Bann, con- 
sisting of about 130, not so many as ten escaped fever, and thirty-eight died ; 
and of the Island of Ascension the garrison, consisting of 36 souls, five only 
escaped fever, and seventeen died.'' 

In 1838, the disease again appeared at the Island of Ascension. The Brig- 
antine Forester arrived at Ascension from Sierra Leone, with the yellow fever 
on board. On her arrival, the sick were disembarked at a cove, from one to 
three miles from the barracks, where the garrison is quartered. A rigid 
quarantine was established on the sick from on board the Forester. 

" The wearing apparel of the deceased commander, Lieutenant Rosenberg, 
was, ITiave been told, taken on shore, and there sold by public auction in the 
garrison. The disease broke out in the garrison about four iveeJcs after the 
Forester's arrival." " The disease, on this as on the former occasion, did not 
appear among the garrison at Ascension until after the arrival of a sickly 
ship, and the actual debarkation on the island of persons labouring under the 
disease." 

The following is another evidence offered by Mr. Pym in proof of the con- 
tagiousness of the yellow fever : — 

" The Eden, on her arrival at Sierra Leone, found two midshipmen on board 
one of her prizes, who had both been attacked by the fever. One died in the 
prize, the other was removed to the Eden on the 5th of May, and died on the 



^ 



1850.] Observations on Epidemic Fevers. 165 

6th. The next that sickened was John Eussel, a seaman, who had volunteered 
from the shore ; he was attacked on the M of May, and died on the 17th. After 
this time, there was not any addition to the list of fever cases until the 12th. ^^ 
Between this latter date and the 1st of June, forty-one cases occurred. The 
whole number of deaths was twenty-five. 

It is by such extremely bald and loose statements that Mr. Pym attempts 
to establish the contagious character of yellow fever. Had we the time, we 
could, from other authentic sources, show that the evidence adduced is worth 
nothing in the settlement of this question. That there is just as much 
evidence, and of a more positive and circumstantial character, to prove that, in 
every one of the instances adduced to prove the introduction into a community 
of the yellow fever from the crews of diseased vessels, and its subsequent 
spread by contagion, the disease originated and was propagated by endemic 
causes alone. A mere perusal of so much of the evidence as Ave have pre- 
sented must convince every unprejudiced mind of its vague and unsatisfactory 
character. 

Mr. Pym makes much use of the introduction of disease into Boa Vista by 
the steamer Eclair, in 1845, in support of his favourite theory. This, we admit, 
is among the strongest portions of evidence he has presented. Judging from 
the documents in our possession, we are forced to acknowledge that the proofs 
of the importation into that island of a very fatal malady, by the steamer just 
referred to, and its subsequent communication from the sick to the well, are 
conclusive. But we have no direct evidence that the disease thus introduced and 
propagated into BoQ. Vista was actually the yellow fever. We confess we have 
strong doubts as to its being so ; and, until this fact is established, the Boa 
Vista fever cannot be admitted as positive evidence that yellow fever can be 
introduced into a community, and subsequently spread among its members by 
contagion. 

The work of Dr. Bryson is a severe and searching review of that of Mr. 
Pym. The author places in bold relief most of the weak points in the state- 
ments and reasonings adduced by the latter in support of his views in rela- 
tion to the true character of yellow, Bulam, or black vomit fever. He has 
also attempted to show a want of ingenuousness on the part of Mr. Pym in 
the quotation of facts, so as to bend them to the support of his opinions, and, on 
more than one occasion, accuses him of keeping out of view evidence invalidating 
that which he adduces. 

As a specimen of Dr. Bryson's manner of handling the work of Mr. P}^!, 
we present the following — and cannot but admit, severe as it is, that it is de- 
served. 

" As Sir William Pym appears to wish it to be understood that his views 
respecting j^ellow fever are peculiar, it may be as well to state, in as few 
words as possible — although that will be no easy task — what they are. In the 
first place, at page 8, he says there are three varieties of fever in warm climates, 
viz.: 1st variety, the bilious remittent, in difierent degrees of concentration, 
prevailing in marshy and uncultivated districts. 2d variety, the bilious con- 
tinued, or sporadic, arising from exposure to the sun, excessive drinking, and 
other irregularities. 3d variety, the Bulam, or vomito-negro, which, although 
a variety of tropical fever, ' is a disease sui generis' (p. 6), ' and differs from all 
others' (p. 67), 'and so far appears to be the offspring of heat, that its powers 
both of contagion and destruction are increased by it to a wonderful degree 
(p. 59).' ' The closer the situation, and the more stagnant the air, the greater 
has been its virulence ;' ' it shows a wonderful predilection for particular 
constitutions' (p. 63). That, although it is capable of naturalizing itself in any 
permanently warm climate (p. 63), 'it is peculiar to Africa ; its source being 
in the interior' (p. 259), yet it attacks natives of that country in a compara- 
tively mild form. That it is not indigenous in the West Indies, but, being con- 
tagious, it leads an erratic existence, ' and has, at different times, been carried 
from the coast of Africa to the West India Islands, and then imported to Europe 
and America' (p. 48). Yet he contradicts this at page 8, where he states, 
* it broke out spontaneously in three companies, quartered in some casemates 
in Fort Edward.' 'That the poison remains dormant only a few days' (p. 65), 



166 BihliogTapMcal Notices. [Jan. 

'and does not affect beyond a few yards' (66). That it is non-remittent, is 
accompanied with bright yellowness of the skin, and black vomit, and that it 
never attacks the same person more than once. 

" In mild cases, of which there are many, it is not distinguishable from other 
fevers from any cause, and, even in bad cases, not until the fatal symptoms occur 
(p. 4). Yet 'it is possessed of peculiarities distinguishing it from all other dis- 
eases' (p. 5). That ' its greatest peculiarity is its attacking the human frame but 
once — and as has been proved (asserted?) to as great a certainty as it has 
been in the small-pox or measles, that peculiarity ought to put the question at 
rest as to its being a disease sui generis' (p. 6). ' It is a disease of a rather 
whimsical character, but regular in its irregularities' (60), and 'it is in no 
way connected with malaria, marshes, or unhealthy situations' (p. 95). 

" He goes on to state that this fever, although it cannot he distinguished in 
the mild cases from fevers arising from any cause, and, in bad cases, not until 
the fatal symptoms occur, yet may be divided into four forms. To those 
who have not seen yellow fever, these infinitesimal divisions may seem rather 
perplexing ; but here follows a sample of the key to the mystery. The first 
symptoms of the first form of the Bulam fever are: languor and chills ; of the 
second, languor and chills, increased to shivering ; of the third, aggravation 
of the latter; of the fourth, nothing but languor, chilliness, and rigor, with 
pains in the loins and calves of the legs. In the first form, the eyes have a 
peculiar shining or drunken appearance ; in the second, they are glassy and 
slightly inflamed; in the third, there is aggravation of all these symptoms ; the 
€yes, therefore, are more shining, drunken-like, glassy, and inflamed ; and, in 
the fourth, the symptoms are not so violent as in the "third ; the shininess, &c., 
is consequently in a degree somewhere between the second and third. 

" To compare the state of the tongue, the pulse, the skin, and various other 
symptoms, would occupy more space and time than I can afibrd, and certainly 
more than the subject deserves. He does not explain how the standard of the 
first form is to be taken, or what degree of aggravation of the symptoms will 
constitute the second form ; or how he manages when several symptoms in- 
crease, and the others are stationary, or retrograde. Anything more prepos- 
terous than the arbitrary division of tropical fever into so many varieties, forms, 
and divisions, can hardly be conceived. Yellow fever, like the fevers which 
infest our lanes and alleys, occurs in different degrees of severity ; but there 
are no means of classifying these, as it will seldom happen that there are two 
cases precisely alike. I have been thus particular in pointing out Sir William 
Pym's peculiar opinions, with regard to the distinctive character of tropical 
fevers, because I think it will go far to prove one of two things, namely, that 
lie has either seen but little of yellow fever, and of that little he has been a 
superficial observer ; or, if he has seen much of it, he has, by confused and 
vague distinctions, depending on accidental circumstances, and by contradic- 
tory statements, endeavoured to obfuscate, and to shroud in mystery, the little 
we do know concerning it." 

" I believe it is generally considered that yellow fever, like other fevers, 
occurs spontaneously in Africa, in America, and in the West Indian Islands ; 
that it most frequently breaks out, and is most fatal (as far as regards Europeans) 
in unhealthy localities ; that, although it has most frequently prevailed in marshy 
places, near the coast, probably from their being most frequented by Europeans, 
yet it has also been observed in dry and hilly situations ; that at one time it may 
attack only a few individuals sporadically ; while at another it may prevail 
epidemically ; that there has not been discovered anything peculiar to it, be- 
yond a general aggravation of the symptoms, sufficient to distinguish it from 
the more severe fevers of the West Indies, and the west coast of Africa, usually 
denominated bilious or remittent ; that it is sometimes contagious, remittent, or 
non-remittent, according to the violence or duration of the attack, many cases 
terminating with one paroxysm ; that it is accompanied by yellowness of the 
skin, differing in shade according to complexion, temperament, the severity of 
the attack, or other accidental circumstances, and frequently with black vomit 
in the fatal cases ; that it may affect the system more than once, but gene- 
rally only at distant periods. Sir William Pym endeavours, not by the pro- 






1850.] Observations on Epidemic Fevers. 167 

duction of reasonable proof, but by reiteration and assertion, to maintain that 
his view of the question is the right one, and that every other, however modi- 
fied, is wrong ; whereas, those who differ from him do so on the authority of 
well-founded facts, which prove incontestably that he attempts to make a dis- 
tinction where there has not yet been discovered any difference ; there not 
being any symptom, or series of symptoms, by which, if there be, as he affirms, 
three distinct fevers peculiar to these regions, each divisible into several sub- 
ordinate forms or grades, the one may be distinguished from the other. Yfith 
respect to remissions, they can hardly be regarded as a fair test of yellow fever, 
unless any, the slightest, abatement of pyrexial action be acknowledged to be 
a remission ; or, if that be denied, until the degree of abatement necessary to 
constitute a remission be specifically defined, and generally admitted. I think, 
however, I shall have little trouble in proving that remissions are by no means 
infrequent in yellow fever. As to the non-liability to a second attack, this, I 
presume, for the present, must remain a disputed point, or, until some few 
persons who have had black vomit recover, and have, at a subseqvient period, 
a second attack, in which black vomit again occurs. But, even then, although 
there is not, perhaps, one in a thousand recoveries from this symptom, the 
superintendent-general of quarantine may take upon himself to assert that 
one of the attacks must have been the bilious remittent fever; in which he says 
black vomit may also sometimes occur, and the fever may terminate without 
a remission.'^ 

We have extended the foregoing quotation from the work of Dr. Bryson to 
a greater length than what we had first intended, as it presents not only a 
tolerably fair critique upon the contradictions and inconsistencies into which 
Mr. Pyni has fallen, in attempting to define his peculiar views in regard to the 
character and causation of yellow fever ; but, also, as expressing an exposition 
of the opinions of the former gentleman upon those important questions. We 
cannot agree with him as to the yellow fever being merely an aggravated form 
of the bilious remittent of hot climates, dependent upon the same causes, and 
distinguishable from it only by the greater violence of its symptoms. If any 
particular in reference to yellow fever has been satisfactorily proved, it is, we 
think, its specific character, and its distinctness from the autumnal remittents 
of the same climates to which it is endemial. This distinctness is shown in 
the difference of the symptoms and progress in the two diseases ; the differ- 
ence in the particular localities in which they occur ; and the very strikingly 
decreased liability of those who have once suffered from yellow fever to a sub- 
sequent attack of that disease ; and the undiminished susceptibility of those 
who have had one attack of bilious remittent to a second attack of the disease. 
And we find that even Dr. Bryson is not so well convinced, as his language in the 
quotation given above would lead us to suppose. After adducing his proofs of 
the assumed identity, which are anything but conclusive, he remarks : — 

" The question as to the individuality of yellow fever has already been partly 
disposed of. This, by the way, is an assumption which I am not prepared to 
demj ; but I am not cognizant of any proof that has been brought forward at all 
calculated to support it ; whereas, there is at least strong presumptive evidence 
that the fever is but an aggravated or an altered form of the endemic. For 
instance, it can hardly have escaped notice that, previous to each successive 
irruption of yellow fever in Sierra Leone, the common endemic gradually as- 
sumed a more concentrated form, until it merged, or seemed to merge, into the 
former ; while, after a time, the diminution in the force of the symptoms, the 
number of attacks, and the proportional mortality, was again equally remark- 
able ; as this form declined or reverted to the common endemic, so intimately 
were the two forms mixed up together, that, as has been already observed, it 
was not possible to tell where the one began, and the other ceased. As far- 
ther evidence in the same line of argument, Staff-Surgeon Ferguson (although 
he latterly adopted the view with respect to the specific character of the dis- 
ease), has remarked: ' Cases of endemic remittent, which have commenced in 
districts not yet visited by the malignant remittent, have become malignant 
on being removed to an infected district.' It has, at the same time, been fre- 
quently observed, that cases of yellow fever, on being removed away from the 



168 Bibliograpliical Notices. [Jan. 

site of their origin, have assumed a milder form than those left in the infected 
spot." 

That upon the yellow fever breaking out in any locality, it should overshadow, 
or blot out, as it were, the ordinary endemic diseases, is not at all surprising — 
and it is equally reasonable to suppose that, upon the disappearance of the former, 
the latter diseases will again make their appearance. But to prove that the two 
diseases are identical, it must be shown that, in numerous instances, the one runs 
into the other ; that, in persons labouring under the ordinary symptoms of bilious 
remittent fever, these, in a shorter or longer period, become changed into those 
of yellow fever, and vice versa. The change in the remittent fever from mild 
to malignant, or a diminution occurring in the intensity of the symptoms of the 
yellow fever, by the removal of the patient labouring under the first to an un- 
healthy locality, and of those labouring under the latter into a more pure and 
healthy atmosphere, is no proof certainly that these two diseases are the same, 
merely differing in violence. 

Dr. Bryson, as we have seen, admits that yellow fever is sometimes contagious, 
and sometimes not — though we cannot understand how this radical change in the 
character of a disease is effected, if the Doctor means by contagion the emanation 
from the person affected with yellow fever of a specific poison, capable, as in 
the case of small-pox, of producing in another, by whom that poison is received, 
a disease similar to that by which the poison was produced. In this sense, we 
deny that a disease can be contagious at one time, and non-contagious at another. 
If Dr. Bryson means to say that, in any instance, the yellow fever is capable 
of being communicated to those who are in contact or attendance upon the 
sick to the well, in a pure, healthy atmosphere, we deny that, in any instance, 
this has occurred. But we suspect that Dr. Bryson uses the term contagious, 
in reference to yellow fever, in a sense in which, though we object to the term, 
we can fully agree with him. Facts innumerable can be adduced to prove the 
propagation of yellow fever under the circumstances alluded to in the following 
quotation : — 

" Believing, as we must do, the testimony of the medical officers of the colony, 
and reasoning from the facts which they have brought forward, and those also 
which have been handed down by other authorities, it is impossible to arrive 
at the conclusion that yellow fever ever became generally contagious in Sierra 
Leone ; that it has been partially so, if we are to be guided by the same data, 
is indeed almost equally improbable, unless we can suppose that the evolution 
of the reproducing virus was but a rare and an accidental occurrence, that it 
was extremely diffusible and lasting, and uncertain in its action, and that its 
influence on the human organism depended on some contingent cause, which 
existed only in the low, damp level immediately contiguous to the river. That 
it became contagious in the Bann, Eden, Forester ; perhaps in the ^tna or the 
Bonetta, or in both ; and in the Eclair, has become clearly established. In 
each of these vessels, there existed that condition under which diseases, not in 
their simple form generally contagious, acquire the property of propagating 
themselves — such as erysipelas, ophthalmia, and synochal fever. The first, in 
vessels of Avar, seems frequently to be governed, with regard to its extension, 
by precisely the same laws as yellow fever. A ship's company may remain for 
years perfectly free from this disease ; but, if two or three cases occur, the pro- 
bability is it will then extend to others, but principally to those who are affected 
with ulcerative disease, and ultimately it may attack almost every man who 
receives the slightest hurt or scratch. In these instances, the contaminating 
poison, it would appear, is propagated through the medium of atmospheric 
agency, and, as in yellow fever, it exerts the baneful influence first on the cir- 
culating fluids. And again, the common synochal or typhoid fevers of this 
country, under peculiar circumstances, such as occur in badly-regulated emi- 
grant ships, rapidly acquire this property, become highly contagious, and fear- 
fully destructive of life. In 1847, the John Bolton left Liverpool with 576 
passengers, all of whom embarked in good health ; before she arrived at Quebec, 
72 deaths had occurred, to which are to be added 35 while she remained in 
quarantine, and 34 more in the quarantine hospital, making a total of 141. 
The Bee, from Cork, out of 352 emigrants, lost on the passage, and in quaran- 



\ 



1850.] Observations on Epidemic Fevers. 169 

tine at Quebec, 165, being, within a fraction, one-half of the number embarked. 
The Avon, from the same place, lost 246 out of 552 embarked. The Virginius, 
out of 476, lost on the passage and in quarantine 267, being 29 more than the 
half. These cases are strictly analogous to those of the Bann and Eclair, and 
clearly enough pointed out the influence which imperfect ventilation, damp- 
ness, and mental dejection have in increasing the destructive powers of febrile 
diseases ; for, even admitting that the seeds of the worst form of typhus existed 
among them when they went on board, still the dreadful aggravation of the 
malady, by accidental circumstances, remains the same. Had these emigrants 
been resident for a short time in Sierra Leone or Fernando Po, and embarked 
under similar circumstances from these places, I have not the slightest doubt that 
fever would, in the same manner, have made its appearance, and would have been 
attended with yellowness of the skin and black vomit, although there had not 
been a case with the latter symptoms at either of those places for months before. 

" How, then, are we to account for the latter symptoms ? Do they depend on an 
epidemic influence, or are they the result of a peculiar morbid action dependent 
on a specific animal contagion, or are they merely the result of febrile action 
operating on, or in conjunction with, an abnormal state of the vital forces, and a 
deteriorated state of the blood? These are questions I shall not attempt, for the 
present, to answer. It may, however, be mentioned, that, as the skin displays 
the yellow tinge, so in proportion is the severity of the disease ; and when this 
is carried one stage farther — when the blood becomes still farther diseased, 
defective in its plastic properties, and oozes from the delicate vessels of the 
mucous tissues — then black vomit occurs ; and unquestionably, under these cir- 
cumstances — particularly in low, damp, densely-populated localities — the dis- 
ease, as is the case in erysipelas, synochal fever of a purely idiopathic form, 
puerperal fever, influenza, hospital gangrene, cholera, and probably other dis- 
eases, becomes contagious.^^ 

Mr. Pym adduces a number of instances as evidence of the introduction of 
yellow fever, in places previously free from the disease, by the arrival of infected 
persons or effects. Of some of these cases of the presumed introduction of the 
disease, Dr. Bryson speaks as follows : — 

"To those who rigidly uphold the doctrines of contagion, the second case 
which occurred in the Sybille, at Fernando Po, should not be without interest. 
Admitting for the moment that it was the result of a personal cause, the virus 
must have been brought from the Eden, either in contact with the clothes or per- 
sons of the marines who came from that ship ; or it must have been conveyed 
simply by the atmosphere, a distance perhaps of a hundred yards ; or, if the 
contagion emanated from the first of the party attacked, who was sent on shore 
before the symptoms were fully developed, then it must be generated at an 
earlier stage of the disease than is generally believed. The first case which 
occurred in the garrison at Ascension, in 1838, is also not undeserving notice. 
It has been shown that the young person, the subject of this case, could not 
have had any communication whatever either with the sick of the vessel in the 
harbor or with their clothes, and, as the wind blows regularly off the land to 
the anchorage, it is not possible to suppose that infection could have been wafted 
from the latter to the shore. There were men sent to the hospital, but they 
came from vessels in which the fever did not exist, and passed to leeward of the 
house in which she resided. 

" Viewing the subject as a contagionist, the re-appearance, perhaps, of the 
disease in the Hecla at Princes^ and certainly in the Sybille for the third time, 
at St. Helena, is not without interest. The time between the death of Mr. 
Tebbs at Bathurst, and the next succeeding case, was thirty days; this, even 
allowing for the incubative stage, is a long period for the retention of the poison 
in connection with inanimate substances: again, at Sierra Leone, by straining 
probability to its utmost, it might be argued that the seeds of the disease re- 
mained in a dormant state for three months in a vessel without a crew." 

" That any animal matter emanating from a living body in a vaporous, or, at 
all events, in an invisible form, should resist decay for weeks or months, seems 
highly, if not altogether, improbable ; but, if this be not admitted, then the fre- 
quent spontaneous evolution of the disease, by proving the existence of a phy- 

) 



170 Bibliographical Notices. [Jan. 

sical or an epidemic cause, will greatly militate, even in the minds of those 
who advocate the doctrine, against the supposition that the fever is so frequently- 
contagious as it would appear to be, were we to admit that the poison germ 
may be shut up in clothes, houses, or ships, for an indefinite period/'' 

Even at the risk of being accused of extending our quotations from the works 
before us to an unusual length, we feel constrained to add, to those already 
given, the general conclusions laid down by Dr. Bryson in regard to the fevers 
of Africa, They show how feeble are the reasons for rejecting the views in 
relation to yellow fever, advocated by those physicians in this country who 
have had the best opportunities for a full investigation of the disease, and who 
have availed themselves of those opportunities to the greatest extent. 

" Without,^' Dr. Bryson remarks, " attempting to offer any theoretical opinions 
of my own respecting the disease, the following conclusions, so far as the fevers 
of Africa are concerned, seem to be clearly deducible. 

" First. It breaks out spontaneously amongst debilitated Europeans, in cer- 
tain localities north of the equator, where fevers of the same type prevail ; and 
as these cease when the former appear, and re-appear when the latter ceases, 
there are no means of accounting for the change but by supposing that the 
one is a modification of the other. 

" Secondly. It prevails principally, and with the greatest malignancy, at low 
levels on or near the sea coast, and in ships of war, from the number of men 
crowded together — it infests 'particular spots, independently of contagion ; a fact 
which has been ascertained, but the cause is not known. ^' 

" Thirdly. It occurs in various degrees of intensity ; the development of the 
symptoms being sometimes rapid, sometimes slow ; some cases terminating with 
one or more paroxysms of fever, and with little detriment to the system, 
within an average period of from two to seven days ; while others, presenting 
precisely the same symptoms, and differing only in degree as respects the 
force of pyrexial action, may terminate within the same period in death. 

" Fourthly. If it be a distinct disease, it cannot in its sporadic form be diag- 
nosed from the common remittent fever of the same regions ; in its epidemic 
form, its existence can only be ascertained or suspected by an unusual increase 
in the number of cases, and the more frequent occurrence of black vomit when 
it proves fatal. 

" Fifthly. It apparently becomes contagious under conditions similar to those 
which occasionally impart the same character to the fevers of the temperate 
zones, erysipelas, hospital gangrene, influenza, and probably cholera ; and, 
under these conditions, it is propagated by the same laws. In proportion to 
the concentration of the poison, all conditions remaining the same, so will be 
the virulence of the disease. 

" Sixthly. On the western coast of Africa, it has on several occasions displayed 
or acquired great malignancy, and the property of propagation on board certain 
ships, and has thus been communicated to Europeans far distant from the site 
of its origin ; but, in the majority of these instances, there existed both in the 
ships and the localities to which it was taken, concurrent circumstances favourable 
to the evolution and propagation of febrile disease.'' 

The caution exhibited by Dr. Bryson in the wording of the foregoing conclu- 
sions, and the candour with which he has stated the facts which militate against 
his own views, while they do great credit to his honesty, give additional force to 
the doctrines of those who believe that the yellow fever is a disease of a specific 
character, produced by other causes than those which give rise to intermittent 
and remittent fever — running its course to a favourable or fatal termination in 
a single paroxysm of from 72 to 120 hours' duration, absolutely non-contagious, 
and only contingently infectious. 

The letter of Sir William Pym on the subject of the Boa Vista fever is a 
criticism, not in the very best taste, of the letter of Sir Wm. Bennett on the 
same subject. As our readers have already been presented with an analysis of 
those documents, upon the facts detailed in which an opinion as to the circum- 
stances under which the fever alluded to originated in the Island of BoS, Vista, 
can be formed, and as the letter of Mr. Pym contains no new fticts calculated 
to place the matter in a clearer point of view, we shall not enter into an exami- 
nation of it. i^- r. C. 



\ 



1850.] Bureaud-Riofrey on Cholera. 171 



Art. XIX. — I)u Cholera; moyens Pr^servoMfs et Curaiifs ; ou Philosophie des 
Grandes Epidemies. Par A. M. Bureaud-Riofrey, Docteur en Medecine de 
la Faculte de Paris, etc. etc. "In rebus angustis animosus atque fortis 
appare. La medecine 6clairee et le bon sens marchent ensemble.'^ Paris 
and London, 1847: 8vo. pp. 116. 

Cholera; its Prevention and its Cure; or the Philosophy of Great Epidemics. By 
A. M. Bureaud-Riofrey, M. D,, &c. &c. 

The author of the present treatise has laid down some excellent rules for the 
prevention of cholera, which, if they M^ere generally followed, would no doubt 
disarm the pestilence, in a great measure, of its mortality, even if they should 
not have the power to prevent its incursion in any given locality. We cannot 
say the same, however, of his therapeutic directions ; they are, certainly, not 
such as experience has shown to be the best adapted to arrest the fatal march 
of the disease. 

Dr. Riofrey's views in relation to the general character of cholera, so far, at 
least, as regards the localities in which it prevails to the greatest extent, and 
with the greatest violence, and the class of persons most subject to its attacks, 
are those to the truth of which we have the almost universal assent of the 
medical profession throughout the world. But, as to the correctness of his 
opinions in relation to the mode of propagation of the disease, but few, we 
suspect, will be found to agree. 

The treatise is pleasantly enough written, and contains a sufficient amount 
of important truths in connection with the subject of which he treats to render 
it worthy of an attentive perusal ; but, upon almost every point on which he 
has touched, he has indulged rather in a species of rhetorical declamation than 
in a close logical analysis of the various facts that have been accumulated in 
regard to cholera, and in their cautious application to the investigation of the 
true cause and character of the disease. 

Dr. Riofrey is a determined contagionist. According to his researches, cho-' 
lera, he informs us, is "an animal poison, which propagates itself by infection, 
as the small-pox, typhus, yellow fever, and plague. This animal poison, efflu- 
vium, miasm, fluid, or, more probably, germ or seed, does not communicate itself 
by contact alone, but by infection. It attaelies itself, in preference, to persons 
who are in a state of debility. Its most constant effect is to depress the vital 
energy ; to alter the composition of the blood ; to weaken all power of reaction, 
and to render the individual incapable of resistance, without the aid of art." 

He insists that the cause of cholera is "an organic entity, a miasm or poison- 
ous germ," which penetrates into the animal organism, and, after a period of 
incubation, develops itself in corrupting all the elements of life. He main- 
tains that this poisonous germ was hatched in the Gangeatic delta, and from 
thence has been carried to produce the disease in every portion of the world in 
which this has appeared. "The human body is," according to him, "the focus 
from whence the cholera exhales and is propagated." 

"If the cholera," our author remarks, "resulted from some change in the 
atmosphere, it should spread over the whole country with a kind of regularity ; 
but, as Coates observes, it, on the contrary, appears to march in lines corre- 
sponding with the great highways, and to have always want of a succession of 
subjects for its propagation." 

" The emanations from the body of an individual affected with cholera are a 
poison. This poison, having once an existence, and being transported by man, 
penetrates wherever man penetrates, in the palace of the prince as in the hovel 
of the poor. It is this poison which destroyed the Grand Duke Constantino, 
Diebitsch, Casimir Perier, and other distinguished persons, notAvithstanding 
they inhabited healthy localities. The unhealthfulness of a locality favours 
and hastens the propagation and the intensity of the cholera; but an individual 
affected with the disease is a focus of infection, and he may of himself infect 
the most healthy locality. Thus, the sequestration of the diseased, and of those 
who have the care of them, is a duty of every government. It is to this measure 



172 Bibliographical Notices. [Jan. 

that Edinburgh, which so much resembles a French city, owes the small amount 
of mortality she experienced from the cholera/^ 

But, while our author insists upon the spread of cholera by a contagious 
matter emanating from the bodies of the sick, he appears to have seen, in the 
unquestionably epidemic character of the disease, some difficulty in the way 
of his theory, and, by a convenient hypothesis, has endeavoured to remove it. 

So generally, during the prevalence of cholera, is the air infected, that Dr. 
E. admits "to protect one's self certainly from the disease, it would be necessary 
to do without air. When once the cholera has appeared in any place, no one 
can say at first in what direction the poison will spread — no one can be 
certain which portion of the atmosphere contains the fatal germ, and which 
portion is free from it. The atmosphere is filled with thousands of germs, that 
become developed wherever they find a soil suitable to them." 

"The epidemic germ, once engendered in a place, corrupts the atmosphere, 
and exhausts in that locality the materials which seem destined to its existence. 
The flame burns so long as it finds an inflammable substance — the cholera con- 
tinues in a house or in a locality so long as it finds debilitated subjects, upon 
which it fixes itself until it destroys them, as certain parasitic animals cause 
the death of those upon Avhom they live. 

"If the epidemic germ, when once hatched, corrupts the atmosphere of a 
locality, it may be understood that the intensity of this corruption will be the 
greatest in the immediate neighbourhood from whence the fatal germ escapes.^' 

"During the prevalence of an epidemic," says the celebrated Delpech, "no 
one feels well, no one escapes a. formal and sensible influence. The miasms, 
whatever be their source, penetrate into all living bodies. No one can know, 
a priori, whether he is or is not in a condition to assimilate the miasms, and 
thus overcome them. An observation, almost universal, demonstrates, however, 
that the severity of the disease is in proportion to the intensity of the focus to 
which the patient has been exposed." 

Thus, the author, while he refers the introduction and propagation of cholera 
to a contagious emanation from the bodies of the sick, weakens his own hypo- 
thesis by admitting the origin of the disease in the mud of the Ganges acted 
upon by a high atmospheric temperature, and that it is only in localities where 
the air is contaminated and stagnant that this contagious germ has full efficiency ; 
while he also invalidates all arguments adduced to prove the communication 
of the disease from individual to individual, by showing himself that, during 
the prevalence of cholera, the air becomes so generally morbific, that all who 
breathe it feel, in a greater or less extent, its poisonous influence. 

It is unnecessary to enter into an examination of the slight support which 
the hypothesis of Dr. R. receives from the history of the rise and spread of 
cholera, and the inefficiency of the strictest quarantine, the most perfect sepa- 
ration of the sick from the well, in preventing its introduction into a locality, on 
the one hand, or its spread among the inhabitants after its introduction, on the 
other. The author has not attempted to adduce any well-authenticated facts to 
show the conveyance, by human diseased bodies, of the contagious miasm of 
cholera, in the first place from the delta of the Ganges, and subsequently from 
the different places in succession at which it made its appearance ; or why it 
should suddenly cease in any locality so long as there existed inhabitants and 
local sources of infection. In the present state of science, it is with facts alone 
and their proper application that we have to do, and not with closet speculations, 
not only unsupported, but directly opposed to a host of well-established facts. 

We scarcely think it necessary to examine the very imperfect and loosely 
expressed code of cholera therapeutics laid down by the author — we see nothing 
in them particularly worthy of note. We would merely hint to the author, that 
the celebrated Dover's powder is not, as he sets it down to be, a mixture of 
calomel and opium. D. F. C. 



1850.] Cholera Statistics. 173 



Art. XX. — Statistics of Cholera; with the Sanitary Measures adopted hy tlie 
Board of Health prior to, and during the Prevalence of, the Epidemic Cholera 
in Philadelphia, in the Summer o/^lS^Q. Chronologically arranged. Prepared 
by the Sanitary Committee, approved by the Board, and ordered for Publica- 
tion, October 10th, 1849. Philadelphia, 1849 : 8yo. pp. 70. 

We must confess that we have been somewhat disappointed in this report. 
It seemed reasonable to expect full and detailed statistics in regard to the 
localities in which the cholera prevailed to the greatest extent, and the classes 
of the population who furnished the greatest proportion of its subjects. 

As an account rendered to the Board, by the sanitary committee, of the manner 
in which they had performed the duties delegated to them, the report is well 
enough ; but when we look into it for the facts upon which are to be based 
permanent reforms calculated to improve the sanitary condition of our city 
and the neighbouring districts, we find only general statements, correct in 
themselves, but which leave us in entire ignorance of the particular points at 
which reform is most imperiously demanded, as well as of the nature of that 
reform. 

We fully believe that the Board of Health both prior to, and during the late pre- 
valence of, epidemic cholera in our midst, performed their duty, and that, by the 
judicious measures adopted and carried into force by them, they were, to a cer- 
tain extent, instrumental in abating the extent of the disease, and in moderat- 
ing its malignancy. But, while their numerous agents were making their visits 
to "all houses, cellars, yards, school-houses, factories, slaughter-houses, streets, 
lanes, alleys, courts, and all other places within their respective districts, where 
nuisances may exist," it would have but slightly increased their labours 
had they been directed to make their reports in such a form as to serve for the 
basis of a valuable sanitary survey of our city and its liberties. 

It does not strike us that "it would have been impossible for the Board 
to enumerate the cases and causes of insalubrity discovered by them, and the 
numerous localities which, hy their exact investigations, were found to be fruitful 
sources of filth and disease.'^ On the contrary, we expected to have received a 
detailed account of those "localities" to which they allude, ''hidden from the 
piiblic eye, where nuisances of the tvorst kind abound, generating and entailing 
disease, and sowing the seeds of physical death upon all around.^' 

The Board could certainly have given "a local habitation and a name" to 
those neighbourhoods Avhere, "day after day, in their personal visits, they 
breathed the pestiferous atmosphere of some degraded or ill-ventilated purlieus, 
where extremes of filth and misery and loathsome disease met the eye, where 
horrid heaps of manure from hog and cowpens, putrefying garbage and refuse 
of every kind, carcasses in disgusting decomposition, filthy rooms, and damp, 
'dirty, and mouldy cellars, full and foul privies in close and ill-ventilated loca- 
tions, gave ofi" their noxious gases." Many of these localities, we are told, "were 
in close proximity to contracted and badly-constructed houses, crowded by occu- 
pants, filthy and poor, without ventilation or drainage, or receptacles for filth, 
or supply of water, or the common comforts of life." 

By indicating these localities, and pointing out the measures best adapted to 
change their condition so that they shall no longer remain sources of poisonous 
emanations, destroying the health and lives not only of those who inhabit them, 
but also of such as dwell in the surrounding neighbourhoods, the Board of 
Health would have conferred an important benefit to the community. By direct- 
ing public attention to the sources of pestilence, their removal would be the 
more quickly and certainly effected. 

Not only is the present report deficient in details adapted to convey precise 
information of the actual sanitary condition of our metropolis, and of the nature 
of the reforms demanded in particular localities to secure the public health, but 
its language throughout is extremely loose and faulty, and in several portions 
of it bears but a very remote resemblance to our vernacular tongue. Such ex- 
pressions as the following are certainly not English: "A system of sanitary ap- 
pliances," " to exercise the prerogative of their position between the disease and 
No. XXXVII.— January, 1850. 12 



174 BibliograpMcal Notices. [Jan. 

the community, that they might be competent to discover the first impression 
from a tainted atmosphere, and arrest the inroads of a pestilential habitude," 
"the accumulation of filth involves a nuisance injurious to public health ;" "the 
doctrine of contagion, a question which has puzzled medical philosophers in 
every age, and which, aided by the light of science and experience, is now un- 
dergoing an alteration which may eventually merge the strict contagious theory 
into a higher generalization/' " Besides these, there were other premises of a 
less objectionable character, but perhaps equally productive of an unhealthy and 
foul atmosphere. '^ We are informed, in one place, that "the appearance of the 
cholera at Staten Island, and its almost simultaneous outbreak at New Orleans, 
is one of those peculiar coincidences which will forever be shrouded in obscurity." 
While in another we are assured that "all the facts connected therewith possess 
intrinsic value, both to the medical profession and the advocates of sanitary 
reform/' Again, at one time we are told that, in their sanitary measures, prior 
to the appearance of the cholera, they were " governed by the broad and y^eW- 
known pri7iciple, that all epidemics are generally obedient to the same laws ;" while, 
at another, we are assured that months before the occurrence of cholera in Phila- 
delphia they were aware that it was " an enemy which disregards all established 
laws of epidemics, and sets at naught all preconceived theories." 

The committee are certainly in error when they assert that the College of 
Physicians united in recommending the closing of the public schools, and the 
use of them as cholera hospitals. 

The following extracts will be interesting to our readers: — 

" The Board issued their first official bulletin May 30th, and continued them 
up to August 18th, inclusive, a period of 81 days. At their meeting on the 18th 
of August, they resolved, that cholera no longer existing as an epidemic, the 
daily bulletin of cases should be discontinued. 

"From this period, a few scattering cases were handed into the Board for 
several days, and the weekly bills of mortality reported deaths from cholera up 
to September 8th. 

" During the 81 days, there were reported to the Board 2141 cases, and 747 
deaths. The largest number of cases and deaths reported were on the 14th of 
July: viz. 84 cases and 32 deaths. On the 12th of July, the highest number of 
cases and deaths were reported from the Almshouse : viz. 24 cases and 14 
deaths. 

" From the 11th to the 14th of July, inclusive, there were 328 cases and 120 
deaths reported, averaging 82 cases and 30 deaths daily, for four days in suc- 
cession. ; ' 

"The cases reported in June, including the two days in May, numbered 278, 
and the deaths 97 ; being 1 death in 2.73. From the 1st to the 18th of August, 
a period of 18 days, 284 cases and 72 deaths, as 1 in 3.94 cases." 

" The following table will exhibit the cases and deaths in private practice, as 
reported to the Board of Health from May 30th to August 18th, inclusive, with 
the ratio of cases and deaths to population, and to each other. 

"It is proper to observe here that, for the same period of time, the weekly 
bills of mortality published by the Board, exhibit the total number of deaths 
from cholera to have been 1012. If from them we deduct the 362 cases occur- 
ring in the Hospitals, Almshouse, and County Prison, we have left 650 cases, 
which will show an additional number of 264 cases, more than the aggregate of 
reports of deaths in private practice made by the Board in their daily bulletins. 

" This discrepancy can be accounted for from the fact, that many physicians 
did not report daily the deaths occurring in their practice, and also, that nume- 
rous cases came under the notice of the coroner, but one of which was reported 
to the Board of Health, and included in their bulletin. In addition to this, some 
persons Avho died in the country were interred within the county limits, and were 
necessarily included in the weekly bills of mortality, while no reports icere made 
severally of their deaths to the Board of Health {?). Nor have we any hesitation 
in believing, that all the cases of cholera which actually occurred in private 
practice were not reported to the Board. A number of practitioners declined 
reporting altogether, while others only reported those of their cases which col- 
lapsed, and others, again, only those that proved fatal. The inference, there- 



1850.] 



Cholera Statistics. 



175 



fore, is, that the result of the table we herewith present, would have been in like 
proportion, had all the cases that were regarded as cholera, as well as the 
deaths therefrom, been reported/^ 



Districts. 


Popula- 
tion. 


Cases. 


Deaths 


Ratio of 

cases to 

population. 


Ratio of 

deaths to 

cases. 


Ratio of 
deaths to 
population. 


City 

South wark . . 
Kensington . . . 
Spring Garden 
Moyamensing . . 
Northern Liberties 
Penn District . . 
Richmond . . . 
West Philadelphia 
Passyunk . 
Unknown . 


118,491 

36,458 

47,697 

54,532 

25,705 

49,321 

7,325 

5,529 

3,413 

1,529 


388 

276 

218 

108 

191 

147 

14 

39 

21 

10 

6 


127 

50 

54 

33 

52 

38 

4 

13 

11 

3 

1 


1 to 305.39 
1 to 132.09 
I to 218.79 
1 to 504.92 
I to 134.58 
1 to 335.51 
1 to 523.21 
1 to 141.77 
1 to 162.52 
1 to 152.90 


1 to 3.05 
1 to 5.52 
1 to 4.03 
1 to 3.27 
1 to 3.67 
1 to 3.86 
1 to 3.50 
1 to 3.00 
1 to 1.90 
1 to 3.33 


lin 933.00 
lin 729.16 
1 in 883.27 
1 in 1652.48 
lin 496.25 
1 in 1297.92 
lin 1831.25 
lin 435.30 
1 in 310.27 
1 in 509.66 


Total 


350,000 


1418 


386 


1 to 246.82 


1 to 3-66 


1 in 906.73 



"From a dissection of this table, we derive some information of a sanitary 
character, which not only possesses interest, but may prove useful in the event 
of a recurrence of cholera, or some other equally alarming epidemic. That the 
epidemic was not confined to any one portion of Philadelphia, but that all suf- 
fered a share of its malign influence. 

"That Southwark, Moyamensing, and Richmond, in the order they stand, 
show the most unfavourable ratios of cases to population, the mean ratio being 
about one in every 136 inhabitants ; while Penn and Spring Garden present the 
most favourable, one in every 514. West Philadelphia shows one in every 162. 
The Northern Liberties gives one in every 335 J. The City one in every 305.39, 
and Kensington one in every 218.79. The increased ratio of cases to popula- 
tion in Southwark must be attributed to its want of cleanliness, its locality, to 
the character of a portion of its inhabitants that reside in the more densely 
populated neighbourhoods, and to its numerous, confined, and ill-ventilated 
courts, and alleys. That of Moyamensing, to the depraved condition of hundreds 
of its inhabitants, to the filthy and crowded condition of many of its small 
houses, inhabited cellars, and their vitiated atmosphere, to the noxious exhala- 
tions from their persons and clothing, and the numerous collections of offensive 
bones and rags, and other ofi'al, heaped up and arrayed for sale in many of their 
small streets. In Richmond, to its locality along the river front, its want of 
proper drainage and sewerage, and also to the character, habits, and occupations 
of a large portion of its population; viz. canal and river boatmen, coal heavers, 
and labourers. 

" In Kensington, the chief cause lies in the unpaved, ungraded, and undrained 
condition of many of its streets. Penn, almost a rural district, elevated and 
dry, and to the N. W. of the city, with a population of 7325, reported only 14 
cases and 4 deaths ; whilst West Philadelphia, sitiiated along the western border 
of the Schuylkill river, with a population of only 3413, gave 21 cases and 11 
deaths ; locality in these two instances must explain the comparative exemption 
of the former from the epidemic, and its increased prevalence in the latter. 

" Spring Garden, next in point of healthfulness to Penn, exhibited only one 
case to every 504.92 of its inhabitants, is situated high above the two rivers 
bounding the city, is well improved, its streets wide, well paved, and graded, 
its underground sewerage many miles in extent, free from a population degraded 
and depraved, and exempt from an excess of crowded and ill-ventilated courts 
and alleys that exist elsewhere. 

" The mean {?) number of cases reported to the Board in private practice was 
1418, and the deaths 386. The ratio of cases to population was one in every 
246.82; the ratio of deaths to population was one in every 906.73, and that of 
deaths to cases as one in every 3.66.'^ 



176 BihliograpTiical Notices. [Jan. 

The bills of mortality, we are told, " exhibit the average [f) ratio of deaths from 
cholera during the season of its prevalence." 

"The sum total is 1012 ; of these, the males amounted to 540, and the females 
to 472, showing an excess of deaths of one-third males over females. But, dur- 
ing the three weeks from June 30th to July 21st, when the disease raged to the 
greatest extent, the proportion was reversed, so that the mortality among females 
was one-sixteenth more than among males. 

"The period of life between 30 and 40 presents the greatest mortality, and 
this ratio is exhibited in all medical statistics, showing a less resistance to dis- 
ease at this age than at any other decimal period. 

" Of the whole number who died, 386 were attended at their own houses; 111 
at the several hospitals under charge of the Board of Health; 229 at the 
Blockley Almshouse, 20 at the County Prison, and 1 unknown. 

"We have not been able to gather the statistics of the epidemic, as it occurred 
among the coloured population, separate and distinct from the mass. This, 
however, is no fault of the Board of Health ; the censure must fall upon the 
practicing members of that profession, who should be most interested in such 
tables, but who, we regret to say, are far too neglectful in making their returns, 
both of deaths and births, with that accuracy which is desirable. All we have 
accomplished under this head, has been to ascertain that 106 people of colour died 
of cholera, and were interred in grounds within the districts, making returns 
to the Board of Health, between the 1st of June and the 8th of September, a 
period of 100 days. Estimating the coloured population at 25,000, would give 
us about one death for every 337, which, it will be discovered, shows a greater 
mortality from cholera among the coloured than the white population. 

"By a reference to the weekly bills of mortality issued by the Board of Health 
for the last four consecutive years, embracing a period of the summer months, 
from the 1st of June to the 1st of September in each year, it will be seen that, 
since 1846, there has been an annual aggregate increase of mortality from the 
four bowel diseases, dysentery, diarrhoea, cholera morbus, and cholera infantum, 
as the following table will show : — 

Choi. Morb. Choi. Infant. Total. 

272 376 
367 552 

388 639 

512 1048 

"The great increase in the deaths from the four bowel affections, for the past 
seasons, and during the prevalence of the epidemic, affords a striking contrast 
to those reported for the three former years, constituting nearly fifty per cent, 
more than either of those years, to which, add the mortality from Asiatic cholera, 
amounting to 1012 deaths, and we have an increase over former rates of more 
than 100 per cent. An evidence, not only, that while an epidemic is prevalent, 
other diseases may prevail with undiminished force ; but that diseases of the 
same class, or partaking of the same congeneric character, are augmented almost 
fifty per cent., and further, that epidemics do not always swallow up, in their 
mighty grasp, other diseases." 

" The ten temporary hospitals, established by the Board, were kept open in 
the aggregate, 408 days." "The whole number of patients received into them 
amounted to 463 ; of these, 344 were cases of epidemic cholera. The remainder 
were affected with cholera morbus, dysentery, diarrhoea, cramp, intoxication, 
fever, and other diseases, sent in by physicians and others, supposed to have 
been labouring under cholera. 

"Of the cholera cases, 278 were whites ; viz. 186 males, and 92 females ; and 
66 were blacks ; viz. 33 males, and 33 females. Among them were 84 Americans, 
and 106 foreigners. As far as the reports showed, there was an excess of pa- 
tients of intemperate habits of nearly fifty per cent., and of the intemperate, 
almost all the cases proved fatal. 

"Of the 344 cholera cases, 111 died, or about 32 per cent, of the whole, equal 
to one in ev-ery three, being a fraction greater than the deaths to cases in private 
practice. The fatality of the blacks and whites, compared to cases, was about 
the same; viz. one in three. 



Years. 


Dysentery. 


Diarrhoea, 


Choi. I 


1846 


37 


55 


12 


1847 


87 


83 


15 


1848 


163 


63 


25 


1849 


337 


137 


62 



1850.] L'ls^re on the Diseases and Special Hygiene of Females. 177 

"The Moyamensing Hospital received almost twice the number of cholera 
patients to any other, owing to its favourable location to that class of the popu- 
lation who would be most likely to need assistance. The mortality to cases in 
this hospital was as one to four. In the Southwark Hospital, 1 to 9.14. In the 
Cherry street Hospital, 1 to 1.92. In the Northern Liberties' Hospital, 1 to 
2.13. In the Richmond Hospital, 1 to 4. In the Kensington Hospital, 1 to 
3.40. In Pine street Hospital, 1 to 1.75. In the Bush Hill Hospital, 1 to 1.90. 
In South street Hospital, 1 to 3, and in the West Philadelphia Hospital, 1 to 
2." D. F. C. 



Art. XXI. — A Treatise on the Diseases and Special Hygiene of Females. By 
CoLOMBAT DE L'IsERE. Translated from the French, with additions, by 
Charles D. Meigs, M. D., Prof, of Midwifery and the Diseases of Women 
and Children, in Jefferson Med. College. Philadelphia, Lea & Blanchard, 

1849 : 8vo. pp. 720. 

The appearance of a second edition of the American translation of the very 
erudite and valuable treatise of M. Colombat is a favourable indication of the 
increased demand upon the part of the profession in this country for good 
works in the different branches of our science. When we find such a work as 
the one before us in the hands of so large a number of American physicians, we 
can almost pardon the encouragement that has been heretofore rather profusely 
bestowed upon compends and manuals. A familiarity with the best productions 
of the best authors will soon banish these from our professional libraries, and 
consign them to their proper sphere — to serve as primers for the use of the 
younger students who have not acquired the technical alphabet of the initia- 
tive branches of medical science. 

We owe our thanks to Professor Meigs for having placed within the reach 
of the great body of the profession in this country, the treatise of M. Colombat, 
and by his name, and the addition of much useful and excellent matter to that 
of the author, rendered it a popular work, while he has very materially en- 
hanced, also, its value. 

The present edition does not vary materially from the first, save in the care 
which has been bestowed in the correction and revision of the translation. 
All those who do not already possess the work, we would recommend to pur- 
chase it, and to make themselves familiar with its teachings, without further 
delay. J). F. C. 



Art. XXII. — The Transaetions of the American Medical Association. 
Instituted 1847. Vol. II. Philadelphia, 1849 : 8vo. pp. 956, 

It affords us pleasure to announce, at last, the publication of this portly vol- 
ume, which contains the minutes of the second annual meeting of the Associa- 
tion, and all the reports of the standing and special committees presented on 
that occasion. Several of these reports are extremely interesting, and we shall 
take an early occasion to notice them. 

The suggestions of the Committee of Publication are deserving of attention, 
and it is to be hoped that the Association, at its next meeting, will take them 
into consideration, and adopt the measures recommended in order to secure the 
earlier publication of its transactions. It is evident, further, from the size of 
the present volume, that the expense of printing will render it necessary for the 
Association to adopt some measures to confine the committees within the limits 
of their appointment, or else to select the more interesting reports only for pub- 
lication. Some of the committees, instead of reporting on the progress of 
medicine in this country during the year of their appointment, have swelled out 
their reports by going back many years, and borrowing largely from the foreign 
abstracts and retrospects. 



178 Bibliographical Notices. [Jan. 



Art. XXIII. — Physician and Patient; or, a Practical View of the Mutual Duties, 
Relations, and Interests of the Medical Profession and the Community. By 
WoRTHiNGTON HooKER, M. D. New York, 1849: 12mo. pp. 453. 

The position of the profession, in regard to the public, is at present altogether 
anomalous. The most erroneous notions have become extensively prevalent 
respecting the relations, interests, and respective duties and obligations of 
medical men and the community. It is among the most cunning devices of 
quackery, to promulgate and disseminate these false doctrines, for, by disturb- 
ing the relations, and impairing the confidence of the sick in their medical 
advisers, the main check to the progress of empiricism is removed, and the 
charlatan can then more readily effect his fiendish purposes, — to fleece the 
public, utterly regardless of the torture and destruction of life he entails upon his 
unfortunate victims. Under these circumstances, we have thought that we should 
be justified, — nay, that we were called on to depart from our rule of confining 
ourselves to the consideration of matters of practical value, — to devote some 
space to the exposition of the highly important subject of ethics. With that view 
we proposed to take as our text, the works of Dr. Hooker [Physician and Patient), 
M. Simon [D4ontologie), and Hufeland {On the Relation of the Physician to 
the Sick, to the Public, and his Colleagues). Circumstances beyond our control 
have prevented, for the present, the execution of this design, but it is not aban- 
doned ; we hope hereafter to accomplish it. In the mean time, we recommend 
most strongly to the profession the volume by Dr. Hooker. It is written in a 
most philosophical spirit, and contains many just reflections worthy of the most 
serious consideration of the profession and equally so of the public. 

The objects of the author are well shown in the following extracts from his 
preface : — 

" The forms which quackery assumes are endless ; but the material out of 
which they are evolved is essentially the same in all ages and in all countries. 
There are certain medical errors which are common to man everywhere and in 
every condition. It is these which constitute the material of quackery, whether 
it appear among the savage or the civilized, the rude or the refined, the illiterate 
or the learned. One object of this book is to develop these fundamental errors, 
and to show the modus operandi by which the genius of imposture has produced 
from them the fantastic and ever-changing shapes of empiricism. I notice par- 
ticularly some of the specific forms of quackery which are now prevalent, not 
because they differ essentially from those which have preceded them, but because 
they have ?i present interest to the reader. 

" One of the objects at which I aim is to expose to the public the fallacy of 
those sources of evidence upon which they rely in estimating the comparative 
merits of physicians, and to showthem what tests they have at command, which 
will not prove fallacious. The proper use of these tests would save the public 
from mistaking, as they now often do, the plausible pretensions of the super- 
ficial practitioner, and the charlatan, for the evidences of real skill and wisdom. 

"Another object will be to present the claims of the medical profession to 
the respect and the confidence of the community. As it now is, the profession 
stands in a somewhat false position before the public. The grounds upon which 
we ask their regard and trust are not generally understood. The confidence 
which is reposed in us is not as intelligent as it should be. It is unsettled and 
capricious. It is overweening at one time, and it is entirely withheld at 
another, and for the most frivolous reasons. The inconsistencies of even the 
well informed on this subject are surprising. Many, who on some occasions 
confide implicitly in nothing but educated science, are found at other times 
submitting themselves and their families to the hap-hazard administrations of 
empiricism." 

/ 



/ 



1850.] 179 



aUAETERLY SUMMARY 

OF THE 

IMPROVEMENTS AND DISCOVERIES 

IHr THE 

MEDICAL SCIENCES. 



ANATOMY AND PHYSIOLOGY. 

1. On the Fcetus in Utero, as inoculating tJie Maternal with the Peculiarities of 
the Paternal Orgajiism ; and on the Injiuence thereby/ exerted by the Male on the 
Constitution and the Reproductive Powers of the Female. By Alexander Harvey, 
M. D. [Monthly Journ. of Med, Sciences, Oct. 1849.) — The subject opened in 
this paper is a very curious one, as also of great interest in general physiology, 
and of practical importance to breeders. Instances are sufficiently common 
among the lower animals, where the offspring exhibit, more or less distinctly, 
in addition to the characters of the male by which they were begotten, the pecu- 
liarities, also, of a male by which their mother had at some former period been 
impregnated, — or, as it has been otherwise expressed, where the peculiarities of 
a male animal, that has once had fruitful intercourse with a female, are more 
or less distinctly recognized in the offspring of subsequent connections of that 
female with other males. [Alison'' s Outli7ies of Phys.) It is interesting to in- 
quire whether this is a general law in animal physiology; and, if it be, whether 
and how far it is modified in its operation in different animals, and under dif- 
ferent circumstances. But to the human physiologist, and to the physician, it 
is of more immediate interest to inquire whether or not the fact extends also 
to his own species ; and, if it does, to ascertain how far it applies, and whether 
it does not admit of illustration by, and serve itself, in its turn, to illustrate 
certain known facts in regard to the communication and the constitutional effects 
of the syphilitic and other morbific poisons, the scrofulous diathesis, &c. And, 
in particular, it can hardly fail to suggest some such curious questions as the 
following, viz. : — 

1st. Whether, in the case of a woman who has been twice married, and borne 
children to both husbands, the children borne to the second husband ever, or 
generally, partake of the peculiarities of the first husband. 

2d. Whether, in a family of several children, the younger children, rather 
than the elder, are disposed, cceteris paribus, to exhibit the characters of the 
father. 

3d. Whether a woman who has borne several children by the same husband, 
may not ultimately acquire some of the physical characters, or at least imbibe 
and manifest some of the morbid tendencies, of the latter. 

In treating of this subject, Dr. Harvey first states the facts at present known 
regarding it, and second, considers the theories offered to explain it. 

The facts of the subject may be most conveniently noticed, 1st, in relation 
to the lower animals ; 2d, in relation to the human species. 

1. In the Brute Creation. — A young chestnut mare, seven-eighths Arabian, 
belonging to the Earl of Morton, was covered, in 1815, by a quagga, which 
is a species of wild ass from Africa, and marked somewhat after the manner 
of the zebra. The mare was covered but once by the quagga ; and, after a 



180 Progress of the Medical Sciences. [Jan. 

pregnancy of eleven months and four days, gave birth to a hybrid which had 
distinct marks of the quagga, in the shape of its head, black bars on the legs 
and shoulders, &c. In 1817, 1818, and 1821, the same mare (which had, in the 
mean time, passed into the possession of Sir Gore Ouseley) was covered by a 
very fine black Arabian horse, and produced, successively, three foals, all of 
which bore unequivocal marks of the quagga. A mare belonging to Sir Gore 
Ouseley was covered by a zebra, and gave birth to a striped hybrid. The year 
following, the same mare was covered by a thorough-bred horse, and the 
next succeeding year by another horse. Both the foals thus produced were 
striped, i. e., partook of the characters of the zebra.* And it is stated by Haller, 
and also by Becker, that, when a mare has had a mule 'hj an ass, and afterwards 
2^ foal by a horse, the foal exhibits traces of the ass.f 

In the foregoing cases, the mares were covered, in the first instance, by ani- 
mals of a different species from themselves. But cases are recorded of mares 
covered in every instance by horses, but by different horses, on different occa- 
sions — where the offspring partook of the characters of the horse by which 
impregnation was first effected. Of this Mr. M^Gillivray gives two examples. 
Thus, in several foals, in the Royal stud at Hampton Court, got by the horse 
Actceon, there were unequivocal marks of the horse Colonel, — the dams of these 
foals were bred from by Colonel the previous year. Again, a colt, the property 
of the Earl of Suffield, got hj Laurel, so resembled another horse Camel, "that 
it was whispered, nay, even asserted, at New-Market, that he must have been 
got by Camel." It was ascertained, however, that the mother of the colt was 
covered, the previous year, by Camel. 

It has often been observed, also, that a well-bred bitch, if she have been im- 
pregnated by a mongrel-dog, will not, although lined subsequently by a pure 
dog, bear thorough-bred puppies in the next two or three litters. J 

The like occurrence has been noticed in respect of the sow. A sow of the 
black and w^hite breed (known as Mr. Western's breed) became pregnant by a 
boar of the wild breed, of a deep chestnut colour. The pigs produced were 
duly mixed, the colour of the boar being in some very predominant. The sow 
being afterwards put to a boar of the same breed with her own, some of the 
produce were observed to be stained or marked with the chestnut colour that 
prevailed in the former litter. And, on a subsequent impregnation, the boar 
iDeing still of the same breed as the sow, some of the litter were also slightly 
marked with the chestnut colour. What adds to the value of the fact now 
stated is that, in the course of many years' observation, the breed in question 
was never known to produce progeny having the smallest tinge of the chest- 
nut colour. I 

Breeders of cattle are familiar with analogous facts as occurring in the cow. 
A pure Aberdeenshire heifer was served with a pure Teeswater bull, to whom 
she had Si first-cross calf. The following season, the same cow was served with 
a pure Aberdeenshire bull ; the produce was a cross calf, which at two years old 
had very long horns, the parents both hummel. || A pure Aberdeenshire cow 
'Was served in 1845, with a cross bull — i. e., an animal produced between a first- 
cross cow and a pure Teeswater bull. To this bull she had a cross calf. Next 
season she was served with a pure Aberdeenshire bull, — the calf was quite a 
cross in shape and colour. f 

* M'Gillivray, "Aberdeen Jonrnal," March 28, 1849. Paintings of these animals 
and their skins are said to be preserved in the Museum of the Royal College of Sur- 
geons of England. 

t Haller, Element. Physiol., viii. p, 104; Becker, Physic, Subterran., Lips. 1703. 
Quoted from Dunglison's Physiology, vol. ii. p. 387. 

J Kirke's Handbook of Physiology, p. 613. 

§ Philosophical Transactions for 1821, p. 23. '-'Apart from a state of domestication," 
says Mr. M'Gillivray, '•'■ I do not believe that there is one solitary instance in which an 
animal has produced offspring of various colours. Animals, left entirely to the operation 
of natural causes, never exhibit this sporting of colours; they are to be distinguished by 
various and often beautiful shades of colour ; but then each species is true to its own 
family type, even to a few hairs or small parts of a feather." 

II M'Gillivray, loc. cit. IT Ibid. 



1850.] Anatomy and PJiysiology. 18Tf 

Mr. M'Gillivray, after narrating the whole of the foregoing examples, says : 
'' Many more instances might be cited, did time permit. Among cattle and 
horses, they are of every day occurrence.'^ 

2. In the Human Species. — The facts bearing on this subject are few, and not 
to be relied upon, and the following observations, Dr. Harvey says, intended 
rather to suggest and direct, than to satisfy, inquiry. 

Dr. Allen Thomson, in his article on generation, in the *' Cyclopsedia of 
Anatomy and Physiology," remarks : " It is affirmed that the human female, 
when twice married, bears occasionally to the second husband, children re- 
sembling the first, both in bodily structure and mental powers." And Dr. 
George Ogilvie, of this city, informs me of a case which fell under his own 
observation, where a woman was twice married, and had children by both hus- 
bands, and where the children by both marriages were scrofulous, although 
only the first husband had marks of that diathesis ; the woman herself, and the 
second husband, being, to all appearance, quite healthy. 

Dr. Ogilvie's case is clearly beset by so many sources of fallacy, that we can- 
not venture at present to regard it as a case in point. Dr. Thomson does not 
bring forward any instances, nor offer any proof, in support of his statement ; 
and, indeed, he gives it, without saying whether he thinks it well or ill-founded. 
Any such statement, it is plain, based on observation of the children of Euro- 
pean parents — i. e., where the female and both her husbands and their children 
are all white — must be comparatively difficult of verification ; but it is equally 
jDlain that means exist for subjecting it to a pretty decisive test. There are 
equally distinct breeds of the human family as of any of the lower animals ; 
and all that seems requisite in regard to determining the question under con- 
sideration is, to observe accurately, whether the children of European parents, 
where the woman has, in the first instance, had off'spring by a negro, exhibit 
traces of the latter in the colour of the skin, the form of the features, &c. ; or 
vice versa, whether the children of negro parents, where the woman had, first 
of all, been impregnated by a European, exhibit the peculiarities of the latter. 
Of the former case, a medical friend informs me that he recollects hearing of 
an instance of the kind as occurring in this neighbourhood, but cannot vouch for 
the truth of it. Of the latter case, if the general fact applies to the human 
species, instances must abound in our West India colonies, in the United States 
of America, and in other parts of the world. My colleague, Dr. Dyce, tells me 
that he has certainly known one instance (if not more) where a Creole woman 
bore fair children to a white man ; and that the same woman had afterwards to a 
Creole man other children, who bore much resemblance to the white man, both 
in features and in complexion. But two very intelligent friends — the one a 
West India proprietor, the other a medical man — both long resident in Jamaica, 
tell me that they never noticed, nor ever heard, of an instance of the kind, al- 
though connections of that sort are common there, and children born under 
such circumstances very numerous. It is singular, indeed, if instances of the 
fact in question do occur, and still more if they are of frequent occurrence, 
that they should not be notorious. It is conceivable, however, and by no means 
improbable, that cases do exist, but that they have been overlooked from the 
traces of the European being so minute as to escape ordinary observation, and 
the fact have remained unknown, from special attention never having been 
directed to it. 

If the male does exert any such influence as is here in question, on the con- 
stitution and the reproductive powers of the female, it is conceivable that, by 
each successive impregnation effected by him, that influence maybe increased; 
and, if so, the younger children begotten by him, rather than the elder, might be 
expected, cceteris paribus, to bear their father's image. And this more special 
fact, if ascertained, would establish also the more general one. I am not 
aware, however, of any specific facts bearing upon it, nor of any popular no- 
tions regarding it. But my colleague. Dr. Laing, is cognizant of the case of an 
English gentleman who had a large family by a negro woman, in the West In- 
dies, and where the children successively exhibited more and more the Euro- 
pean features and complexion. 

But, however this may be, there is a popular belief that, in the course of 



182 Progress of the Medical Science. [Jan. 

years, a woman comes to resemble her husband, and that not merely in respect 
of temper, disposition, or habits of thought, but in bodily appearance. But, in 
so far as the notion may hold good, it may be true only of the features, and of 
these only as they indicate or bespeak the inward feelings of the mind, which, 
from long and familiar intercourse, may, to a certain extent, become common 
to man and wife. In so far as the notion is true in any other respect, and the 
parties have had several children, it may suggest the question, whether the 
assimilation is not referable to an influence exerted by the husband, through 
the medium of the foetus in utero, on the constitution of the wife ? The ques- 
tion is probably an idle one, and the notion only a popular error. In so far, how- 
ever, as there is anything in it, the explanation suggested gives a peculiar, and, 
it may be added, a physiological significancy, to the language of Scripture rela- 
tive to man and wife, at least when their intercourse has been fruitful — " They 
twain shall be one JieshJ' 

It is of more immediate interest, however, and of greater practical moment, 
to ascertain whether, through the medium of the foetus, the husband may im- 
part to his wife either the syphilitic virus, or the scrofulous diathesis, or any 
other constitutional morbid tendency (e. g. insanity) which he may possess. 
Facts are wanting on this subject ; but it is not undeserving of patient inquiry. 
Dr. Ogilvie's case, formerly referred to, if it could be relied on, would be an 
instance of it. Before the mother could have imparted the scrofulous taint to 
her offspring by the second husband, she must herself have imbibed it from her 
first husband through the medium of his offspring while in utero. And, al- 
though still seemingly free of the taint, it may have required only the appro- 
priate external conditions to call it into full activity in her own person. And, 
with regard to the syphilitic poison, there is no difficulty in understanding, and 
it is quite within the bounds of probability, that the foetus, if contaminated 
with it by its father, may convey it to the mother. Messrs. Maunsell and 
Evanson, after mentioning that they have notes of the case of a syphilitic child, 
whose mother had been infected by a former husband (they do not say in what 
way) — and to all appearance, cured five years before its birth — the father of 
the child (her second husband) being in good health, state that their experience 
would enable them to adduce many curious facts bearing on the communication 
of the syphilitic poison.* Perhaps their experience might furnish an affirma- 
tive solution of the question at issue. It has been affirmed, indeed, that a man 
who has once had syphilis, but been seemingly cured of it for many years, may 
yet so retain the taint of it as to contaminate his offspring, without, at the same 
time, tainting his wife. Very possibly. But this does not prove that he may 
not contaminate his wife also ; and the observation itself is in that respect fal- 
lacious, inasmuch as, in any given case of the kind, the wife may really have 
imbibed the virus, although in a latent form, and might subsequently give proof 
of the reality of the fact by tainting the offspring begotten by another and a 
perfectly healthy husband. Adopting this view, it may be found of importance, 
in contemplating marriage with a widow, to inquire into the constitutional 
peculiarities of her deceased husband ! 

The following additional cases, illustrative of this question, have recently 
been communicated to Dr. Plarvey; the first by the Rev. Charles M'Combie, of 
Tillyfour, minister of Lumphanan, in Aberdeenshire ; the second by Professor 
Simpson, of Edinburgh ; and the third by Professor Pirrie, of Aberdeen : — 

1. Mrs. , a neighbour of Mr. M'Combie, was twice married, and had 

issue by both husbands. The children of the first marriage were five in num- 
ber; of the second, three. One of these three, a daughter, bears an unmistake- 
able resemblance to her mother's first husband. What makes the likeness the 
more discernible is, that there was the most marked difference, in their features 
and general appearance, between the two husbands. 

2. A young woman, residing in Edinburgh, and born of white (Scottish) 
parents, but whose mother, some time previous to her marriage, had a natural 
(mulatto) child, by a negro man-servant, in Edinburgh, exhibits distinct traces 
of the negro. Dr. Simpson, whose patient the young woman at one time was, 

* On the Management and Diseases of Children, 5th edit., pp. 452, 453, 



1850.] Anatomy and Physiology. 183 

has had no recent opportunities of satisfying himself as to the precise extent 
to which the negro character prevails in her features ; but he recollects being 
struck with the resemblance, and noticed particularly that the hair had the 
qualities characteristic of the negro. 

3. Mrs. H , apparently perfectly free from scrofula, married a man who 

died of phthisis. She had one child by him, which also died of phthisis. She 
next married a person who was to all appearance equally healthy as herself, 
and had two children by him, one of which died of phthisis, the other of tuber- 
cular mesenteric disease — having, at the same time, scrofulous ulceration of the 
under extremity. 

Great difficulty has been felt by physiological writers, in regard to the proper 
explanation of this kind of phenomena. They have been ascribed by some to 
a permanent impression made somehow by the semen of the first male on the 
genitals, and more particularly on the ova, of the female ; and by others to an 
abiding influence exerted by him on the imagination of the female, and operat- 
ing on her mind at the time of her connection subsequently with other males, 
and perhaps during her pregnancy. But they seem to be regarded by most 
physiologists as inexplicable. 

Very recently, in a paper published in the "Aberdeen Journal,''^ an intelli- 
gent veterinary surgeon, Mr. James M'Gillivray, of Huntly, has offered an ex- 
planation, which seems to Dr. H. to be the true one. His theory is set forth in 
the following statements quoted from that paper : " When a pure animal of 
any breed has been pregnant to an animal of a different breed, such pregnant 
animal is a cross ever after ; the purity of her blood being lost, in conse- 
quence of her connection with the foreign animal;" and again : " If a cow, say 
of the pure Aberdeenshire breed, is in calf to a bull of the short-horn breed 
(known as the Teeswater breed), in proportion as this calf partakes of the 
nature and physical characters of the bull, just in proportion will the blood of 
the cow become contaminated, and herself a cross, for ever incapable of pro- 
ducing a pure calf of any breed." "It is maintained, therefore (Mr. M^Gil- 
livray adds), that the great variety of non-descript animals to be met with 
are the result of the crossing system: the prevailing evil of which is, the ad- 
mission of bulls of various breeds to the same cow, lohereby the blood is completely 
mtiatedr 

Mr. M'Gillivray is probably quite wrong in assuming that there is a direct 
vascular connection between the foetus and its mother ; but this, as Dr. Harvey 
observes, is not necessary to establish the theory ; " perhaps," he says, " the 
best general expression of the theory is, that the foetus, partaking as it must 
of the characters or peculiarities of its father, inoculates therewith the blood, 
and, generally, the system of its mother." 

" In connection with the constitutional influence exerted by the male, through 
the medium of the foetus in utero, on the system of the female, another and a 
very singular question," says Dr. H., " may be raised. In the case of an abo- 
riginal woman of colour, does previous impregnation by a European male ren- 
der the female incapable ever after of fruitful intercourse with a male of her 
own race ? 

" This question is suggested by an observation, made in various parts of the 
world, by the excellent Count de Strzelecki, relative to the efiect of fruitful in- 
tercourse between an aboriginal female and a European male. ' Whenever 
such intercourse takes place, ^ says the Count, ' the native female is found to lose 
the poioer of conception, on a reneioal of intercourse with a male of her own racCy 
retaining only that of procreating with the white men.'f 

" This, if a general fact, contrasts remarkably with Dr. Simpson's case, above- 
mentioned (one of fruitful connection between a white man and a white woman, 
after previous impregnation of the latter by a black man), unless, indeed, this 
be, which probably it is not, an exception to an equally general fact of the same 
sort. It would limit, also — nay, absolutely exclude — opportunities of observing 

* March 2 J and 28, 1849. 

j- Physical Description of New South Wales and Van Dieman's Land, p. 347. 



184 Progress of the Medical Sciences. [Jan. 

whether children born of dark parents, where the mother formerly had issue 
by a European male, exhibit traces of the latter. But it was before stated (p. 
1135), on the authority of two gentlemen long resident in Jamaica, that, in our 
West India colonies — in Jamaica, at least, — fruitful connections of this kind 
are of common occurrence (which I mention at present as in keeping with 
this) on the authority of Dr. Dyce, that, in children born under such circum- 
stances, marks of the European have been observed. Special inquiry, made 
recently, has served so far to confirm these statements, but not to satisfy me that 
the issue of such connections is numerous. 

"The opportunities, however, enjoyed by the Count de Strzelecki, of making 
observations as to this point, in most parts of the New World, have been very 
great. ' He has lived much (to use his own words) amongst different races of 
aborigines, — the natives of Canada, of the United States, of California, of 
Mexico, the South American Republics, the Marquesas, Sandwich, and Society 
Islands, and those of New Zealand and Australia.^^" And, referring to the 
statement made by him, and already quoted, the Count observes — ' Hundreds 
of instances of this extraordinary fact are on record in the writer's memoranda, 
all recurring invariably under the same circumstances, amongst the Hurons, 
Seminoles, Red Indians, Yakies (Sinaloa), Mendosa Indians, Araucos, South 
Sea Islanders, and natives of New Zealand, New South Wales, and Van Die- 
man's Land ; and all tending to prove that the sterility of the female, which is 
relative only to one and not to another male, is not accidental, but follows 
laws as cogent, though as mysterious, as the rest of those connected with gene- 
ration.' "f 

2. On tlie Production and Disappearance of Sugar in the Animal Economy. 
By M. Magendie. Production of sugar in the economy. — After describing the 
various modes in which sugar may be detected in the animal economy, M. 
Magendie observes, that, although it had been long knoAvnthat sugar was formed 
in the urine, the mode of its formation only became known when the formation 
of that in vegetable bodies was discovered. If starch, derived from potatoes 
or other bodies containing it, is brought into contact with acids, sugar is found, 
and the same takes place if a ferment is added to it ; dextrine, and then glucose, 
being formed in this latter case. This result is due to an active principle, found 
by MM. Payen and Persoz, in germinating barley, and called by them diastase, 
on decomposing which we obtain nitrogen, as well as oxygen, hydrogen, and 
carbon. How does this body separate the dextrine from the starch? How does 
it convert it into sugar and alcohol? It is a mystery; and to merely state 
that it is by catalysis, is only to avow our ignorance. We must, therefore, content 
ourselves with studying the phenomena. Thus, if we add iodine to a solution 
of starch, we produce a violet colour. If, in the same solution, we place a little 
diastase, the colour becomes rose, and, a little later, red — demonstrating first 
the existence of dextrine, and then that of sugar, which is afterwards pro- 
duced. 

Are there not, in the animal economy, analogous conditions to these, in which 
diastase is formed ? The recent discovery of sugar in the economy, by M. Ber- 
nard, renders the inquiry one of the greatest interest. So many substances of 
the animal economy possess this power, as well as diastase, of transforming 
starch into sugar, that the greater difficulty would be, to point out those that do 
not possess it. 

In respect to the action of the saliva, there are some distinctions to be ob- 
served. First, its quantity varies much in different animals. In the horse, for 
example, whose food requires prolonged mastication, it exists in very large 
quantities ; there is but little in the dog and most carnivora, and hardly any in 
the cat. Again, the question whether the three salivary glands all furnish a 
similar fluid, has not been hitherto determined. The property of converting 
starch into sugar by the action of the animal diastase, is a means of deciding 
this. In the horse, a large alimentary bolus is formed, which remains long in 
the oesophagus, and the transformation of the amylaceous matter of its food 

* Physical Description of New South Wales and Van Dieman's Land, p, 345. 
t Op. cit., p. 347. 

\ 
( 

c 



1850.] Anatomy and Physiology. 185 

may be ascertained if we tie this canal. But if, by an opening into the parotid 
duct, we remove the fluid of the parotid gland, before it reaches the mouth, and 
place it in contact with starch, no such conversion into sugar occurs. It is the 
same, also, with the saliva drawn from the maxillary ducts in the dog. There 
is, then, in the buccal saliva something peculiar, dependent upon ail its con- 
stituent principles. In fact, we have the fluid of the three glands united, mucus, 
atmospheric air, the absorption of oxygen, and a tendency to produce carbonic 
acid. The pancreatic fluid of itself effects the transformation. 

Can the gastric juice convert alimentary bodies into sugar ? It is a singular 
circumstance, that sometimes starch is promptly thus transformed, and some- 
times not at all. The transformation takes place, if the juice is alkaline, like 
the saliva, but not if it is acid. If the acid gastric juice does not transform 
starch into sugar, it possesses the power of dissolving azotized aliments, such 
as meat. This difierence in the juice, according as it has to act upon amyla- 
ceous or azotized substances, is one of M. Bernard's important discoveries, 
whence therapeutical applications may flow. As the acid of the stomach is the 
lactic, it is this we should prescribe for individuals whose digestion of animal 
food is difiicult; while alkaline drinks are proper for those who digest vegetable 
aliment with difficulty. 

Starch is also transformed into sugar in the intestinal canal, as shown ex- 
perimentally by M. Magendie. The same change takes place when it is placed 
in contact with a solution, an infusion, or a decoction of the brain, spleen, 
pancreas, &c. The urine itself can effect this transformation. So, too, if starch 
be introduced by injection into the blood, it is converted into sugar. Thus, 
almost all parts of the body may contribute to transform alimentary starch into 
sugar ; but the liver alone has the property of producing sugar loitkout starch, 
as shown by M. Bernard's investigations. This same distinguished chemist has 
more recently shown that this production of sugar by the liver is under the 
influence of the nervous system. M. Bernard, after several experiments, dis- 
covered that, if the floor of the fourth ventricle is pierced within a very 
circumscribed space, in less than half an hour a very considerable quantity of 
sugar was found in the blood and urine, without the regimen of the animal 
having undergone any change whatever. This curious fact has naturally directed 
attention to the condition of the floor of the fourth ventricle in diabetic patients ; 
and, in a recent autopsy, two dark spots, at the place where the part must be 
penetrated in order to produce the sugar, were observed. M. Bernard has been 
enabled to produce the same phenomenon in another manner, viz., by pricking 
or gently galvanizing the eighth pair in the neck ; but the increased secretion 
so produced is of short duration. Another experiment, by its negative results, 
affords additional proof that this secretion of sugar is under the influence of the 
nervous system. The two nerves of the eighth pair are divided in the neck of 
the rabbit; and, if the animal survives the operation for some hours (which is 
necessary, in order that the sugar already formed in the liver may pass away 
into the circulation), the liver no longer, however treated, offers any traces of 
sugar. 

The transformation of amidon into sugar, as also the natural production of 
sugar in the liver, appears, then, to be one of the great functions of the eco- 
nomy—one of the true conditions of existence. In late times, animals have 
been denied the property of producing sugar or fat, these bodies existing ready 
formed in the aliment. All now stated demonstrates, however, that the animal 
machine is not only a true sugar manufactory, but that it may even produce it 
without requiring even the alimentary starch for the purpose of conversion. 

Disappearance of sugar from the economy. — In proportion as sugar is formed in 
the liver, it is carried away by the venous and arterial currents which traverse 
that organ, and it should therefore be found in the vessels proceeding from it; 
and M. Bernard has found it in the supra-hepatic veins, in the vena cava 
superior, and in the right cavities of the heart. But in other parts of the body 
the blood contains no sugar, or only very feeble traces of it. It is found neither 
in the veins constituting the vena cava inferior, in this trunk itself, nor in the 
splenic veins, and scarcely any traces are found in the blood of the veins return- 
ing from the head. Nevertheless, for about five hours after the digestion of 



186 Progress of the Medical Sciences. [Jan. 

amylaceous substances, a notable quantity of sugar may be found in all the veins. 
This lapse of time shows that the sugar is destroyed only gradually, and that it 
is necessary for it to pass a great number of times through the lungs before it 
disappears entirely. Since we do not find the sugar produced by the liver after 
it has traversed the lungs, it must become destroyed in these organs. Here, 
then, is an entirely new fact. Something takes place in the respiratory process 
which was entirely unknown. May not this be the cause of animal heat ? In 
spite of all the ingenuity of the illustrious Lavoisier's theory, he supported it 
by no direct proofs ; for it is not only oxygen, but also nitrogen and hydrogen, 
which, passing into the blood, produce carbonic acid. There is nothing impos- 
sible, then, that from the destruction of sugar in the lungs the carbonic acid of 
respiration may result. [This doctrine has long been taught in Great Britain, 
especially since the researches of Dr. Buchanan of Glasgow demonstrated the 
existence of sugar in the blood, for a short time after the use of amylaceous 
articles of food.] 

Respiration does not act in the same manner in the destruction of all species 
of sugar. If we inject a solution of cane sugar, mannite, or the sugar of milk, 
the whole of this sugar is found in the urine ; but if we inject glucose or grape- 
sugar, unless a large quantity has been thus introduced, we do not find any in 
the urine. But, if the first-mentioned descriptions of sugar are not destroyed 
in the lungs, this is no longer the case when animals are fed by them. In this 
case, we no longer find cane-sugar in the urine, because, by digestion, it has been 
transformed into glucose, and decomposed by the lungs. Under these difierent 
circumstances, sugar is always tending to disappear from the economy. The 
first-named species, escaping the respiratory act, are eliminated by the urine ; 
while glucose, which is the sugar of diabetes, is destroyed in the lungs. 

The following table exhibits the quantity of the different kinds of sugar it is 
necessary to inject into the jugular, in order that they may be detected in the 
urine. Thus, there are physiological differences nowise indicated by chemistry • 
and it will be especially remarked that the sugar of the liver, i. e. the natural 
sugar of the economy, is destroyed in the act of respiration with far greater 
facility than the sugar proceeding from alimentary substances : — 



Cane-sugar, 



0.05 



Mannite, ..... 0.05 

Sugar of milk, .... 0.25 

Glucose, ..... 2.50 

Sugar of the liver, .... 12.00 

Applications. — There are only two diseases known, in which the quantity of 
sugar in the economy has been proved to be increased, phthisis and glucosuria. 
It had been long observed that the urine, as well as the expectoration, of 
phthisical patients is sometimes saccharine ; but a distinction must be made 
between such cases and those which only become phthisical as a result of dia- 
betes. M. Bernard declares that the urine in true phthisis is not saccharine ; 
but that the quantity found in the blood is much increased. Having observed 
such increase in the blood of a young girl, who had been bled, and whose urine 
exhibited no sugar, he predicted, although no other sign of phthisis was present, 
that she would fall a victim to this disease, which she did. But researches into 
this subject require to be multiplied. It is certain that diabetes induces, as one 
of its consequences, the most serious pulmonary affections ; and now that we 
are aware that one of the functions of the lungs is to destroy the sugar as it is 
formed, we cannot be surprised at their becoming fatigued in the effort to 
decompose all that is formed. For this they do not suffice, and an immense 
quantity escapes by the urine. It is also found in the expectoration, in the 
matters vomited and passed by stool (M. Magendie has found large quantities in 
the cholera evacuations), and in the sweat. In this disease, which is character- 
ized by emaciation, we find weakness of sight, loss of the generative faculties, 
sleeplessness, an excessive thirst, a voracious appetite, and active digestion, as 
if to furnish material for this incredible activity of fabrication ; but, under this 
terrible influence, consumption arrives, and the patient is sometimes carried off 
with great rapidity. 



1850.] Anatomy and Physiology. 187 

Two distinguished chemists, MM. Bouchardat and Mialhe, have recently 
offered their explanations of the mode of production of this affection, and sug- 
gestions as to the best means of coping with it. According to M. Bouchardat, 
the diabetic urine proceeds from the transformation of fecula into sugar, and 
the quantity of this will be found to be great in proportion to the quantity of 
bread and feculent aliment consumed; and he advises a modification of the 
animalized regimen which had already been employed by Rollo, Thenard, Du- 
puytren, &c. He gives also a glutinous bread, containing only one-fifth of flour, 
and endeavours to regulate the functions of the skin by warm clothing, exercise, 
and the use of baths. In obstinate cases, he thinks well of the carbonate of 
ammonia as a medicine, only using the bicarbonate of soda when the glucose is 
in moderate quantity, and the urine simultaneously contains uric acid. Lime- 
water and magnesia, by retarding the solution of feculent matters, become use- 
ful adjuvants, being, however, of only temporary avail. According to M. Mialhe, 
the defective decomposition of sugar, and its passage into the urine, depend 
upon the insufficient alkalescence of the humours ; it being, in his opinion, by 
the instrumentality of the alkalies of the blood and of the animal fluids, that 
digestion of amyloid and saccharine substances is effected. Ilis treatment 
consists in the administration of the alkaline waters of Vichy, and the re- 
establishment of the functions of the skin, the alimentation becoming then a 
secondary consideration. To both these views of the nature of the disease, the 
natural production of sugar in the liver and the saturation of the blood by it 
when the eighth pair are excited at their origin, or in their course, present 
serious objections. To M. Mialhe's view may also be opposed the facts, that the 
blood, only slightly alkaline in its normal state, does not become acid in dia- 
betes, and that a more alkaline fluid than it has been found, by M. Magendie's 
experiments, not to decompose the glucose. The serum of the blood of the horse 
is less alj^aline than is that of man, and yet the sugar is just as easily destroyed 
in the one as the other. In fact, it is not by the alkali of the blood that such 
destruction is effected, but, as shown by M. Magendie, by the respiratory action. 
M. Bernard believes the disease to be an affection of the pneumogastric nerves: 
but we may also ask whether, in some cases, it may not arise from some peculiar 
alteration in the liver. — Brit, and For. Med.-Chirurg. Rev., Oct. 1849, from a 
Report of M. Magendie' s Lectures at the College de France, by M. Fauconneau- 
Dufresne. V Union Medicale, Nos. 72, 75, and 79. 

3. On the Physiological Anatomy of the Spleen. — Br. W. R. Sanders arrives 
at the following conclusions, which he gives at present without any details : — 

I. The Malpighian glandulse or sacculi, and the pulp of the spleen, constitute 
a true secreting apparatus. 

A. The Malpighian sacculi are hollow, spherical, membranous bags, completely 
closed, and filled with organized contents ; they are attached to the trabecules 
by an arterial pedicle, and are imbedded in the pulp. 

Saccular Membranes. — The outer membrane of the sacculi is fibrous, and 
contains arterial ramifications and numerous capillaries ; their inner membrane 
is granular. 

Saccular Contents. — On the inner surface of the membrane is applied a com- 
plete layer of nucleated cells ; which are clear (not granular), of about l-1200th 
inch diameter, and of a light yelloAvish colour, when not altered by the action 
of water. The rest of the interior of the sacculus is filled up by free corpuscles 
(containing nucleoli) of a light grayish colour, and of about l-4000th inch dia- 
meter, corresponding precisely with the nuclei of the cells, and by a homo- 
geneous or slightly granular plasma. 

The perfection of the forms, the constancy and uniformity of appearance of 
these corpuscular elements, together with their reactions under water, acetic 
acid, &c., are extremely characteristic, so that they are easily and distinctly 
recognized. There is also evidence of the growth and maturation of the sac- 
culi. This part, therefore, of the glandular anatomy of the spleen exhibits 
characters as perfect and as truly distinctive as the glandular elements of the 
liver, kidneys, salivary glands, &c. 



188 Progress of the Medical Sciences. [Jan, 

The sacculus is the formative secreting organ, analogous to the acini of known 
secreting glands. 

B. The splenic pulp consists, like the contents of the sacculi, of plasma and 
corpuscles ; but the nucleated cells are extremely few, and mostly granular — 
hence the reason why they were not detected by observers who did not examine 
the sacculi apart from the pulp with sufficient care ; the plasma is full of gran- 
ules, which are distinct, and infinitely more abundant, than within the sacculi ; 
and the corpuscles, instead of a regular uniform shape, are mostly angular, 
deformed, with great variety of shape and appearance, and hrealdng up into 
granules. These corpuscles are often, also, of a reddish colour ; and, besides 
them, coloured semi-crystalline particles, of a deep red or yellow hue, and whose 
true relation is not yet perfectly made out, are found in the pulp. 

The pulp is, therefore, that part of the glandular apparatus where the cor- 
puscles of the spleen become disintegrated and dissolved into granules and 
plasma ; and, if the sacculi are analogous to acini, it is probable that they burst 
and effuse their contents into the pulp, where they undergo degenerating changes, 
becoming thus fit for absorption : the pulp being a reservoir or dud, in which 
the secreted product is lodged for a time, and undergoes the ulterior changes of 
maturation and solution. 

II. The veins are the absorbent elements of the spleen, and carry away its 
secretion. 

This is rendered probable by their extraordinary number and size ; by their 
abundant ramifications in the pulp (while the arteries are spread over the se- 
creting sacculi) ; by evidence derived from the composition of the splenic venous 
blood, as shown in Beclard's recent comparative analysis of splenic and other 
venous blood [Archives Generates cle Medecine, Oct., Nov., Dec, 1848) ; and by 
general analogy in the nature, functions, and relations of the portal circulation 
in the adult and in the foetus. 

III. The blood circulation within the spleen is peculiar, but the peculiarities 
are not confined to the venous circulation, as has been generally supposed, but 
are common to it with the arterial. Its general principle is, " the sudden and 
immediate transition from very large to very small vessels," which renders the 
circuit of the blood-current extremely short. This general rule does away with 
all the minor differences of vascular distribution found in the spleens of man, 
the horse, dog, &c., compared with those of the sheep, bullock, &c. 

The venous cells of the spleen, though, under certain circumstances, an un- 
doubted appearance, are entirely artificial, and alwa-ys produced by methods of 
preparation, on which no reliance should be placed. 

There is no satisfactory evidence that the lymphatics are the excretory ducts 
of the spleen; nor that its fibrous tunic or trabeculae are muscular, or anything 
more than very elastic. 

Conclusion. — The spleen is a true secreting gland ; and its product, which is 
some organized or organizable albuminous compound, is absorbed into the venous 
blood of the portal system, and contributes, but is not essential to nutrition. 

The elements here mentioned are constant : they are easily made out in the 
spleens of the bullock, sheep, &c., when quite fresh. In the human spleen, they 
are in general less easily analyzed ; but the microscope shows them to be iden- 
tical, and, further, thus affords the means of recognizing and establishing the 
existence of the Malpighian sacculi, when (as not unfrequently happens in the 
human spleen) they are not visible to the naked eye, or, at least, not distinguish- 
able from the pulp.—ifec?. Times, April 21, 1849. 

4. On the Medullar?/ Substance of Bones. By MM. Gosselin and Regnauld. — 
Most anatomists have in general terms described the existence of a medullary 
membrane supporting and surrounding the medullary substance ; but when 
they enter into particulars concerning it, they declare its tenuity to be such that 
its existence is demonstrated with difficulty. In the present paper, the authors 
declare that careful examination conducted by the naked eye, the microscope, 
and chemical tests, in a great variety of cases, have convinced them that, in 
point of fact, no such membrane does exist, the doubts already expressed by 
•Ruysch, in respect to it, becoming thus fully confirmed. 



/ 



1850.] Anatomy and Physiology. 189 

The medullary substance presents very different appearances, not only in 
different species of animals, but even in different individuals. The modifica- 
tions may be classed under two principal heads, which, for distinction's sake, 
we may term the fatty medulla and the gelatiniform medulla. In the first of 
these, it almost entirely consists of semi-fluid, fatty substance, and of extremely 
delicate vessels forming a network on its surface and in its substance. In the 
other, there is but a small proportion of fatty matter, the substance then hav- 
ing the appearance and consistence of a red jell}^ the vascular network being 
here still more abundant. Both these varieties are compatible with health, the 
substance containing more or less fat, according to peculiar predisposition. 
Disease, however, exerts its influence, and under the operation of inflammation 
fat is absorbed, that part of the skeleton then presenting the gelatiniform type, 
even while the other parts present the fatty. Long-continued general disease 
may similarly affect all the bones ; but the differences which result are so great, 
that no general rule can be laid down. Age, however, has a more marked and 
constant influence. In early life, the substance is very vascular and gelatiniform, 
and does not present the colour of fat ; but as development advances, the fatty 
type is gradually assumed, though not completely until after the consolidation 
of the epiphyses. The same appearances present themselves, whether the sub- 
stance is examined in the medullary canal of a long bone, or in the cellules of 
the spongy tissue. 

Originally, the medullary canal is but a canalicule, containing a much larger 
artery than the other canalicules, which freely ramifies into the substance of the 
bone. These and the accompanying venous ramifications afterwards become 
mingled with some adipose cells, and with a matter which, though not gelatine, 
much resembles it. As ossification goes on, this canal becomes enlarged by the 
absorption of its inner layers, for the purpose, as shown by M. Fiourens, of 
affording the long bones a greater power of resistance without increasing the 
quantity and weight of osseous matter. In proportion as this absorption of the 
innermost layers of the canal takes place, the adipose or gelatiniform matter is 
deposited, filling up the empty spaces, supporting the vessels, and keeping an 
abundant vascular network applied against the internal surface of the canal ; 
its of&ce, though important, being purely mechanical. The fat of the bones, 
then, differs from that of other parts of the body in not being divided into lobes 
or lobules by prolongations of the membranous areolar tissue. The cells are 
separated only by delicate capillaries, and are mingled with more or less gela- 
tiniform matter. Just as the vascularity is great, the proportion of fatty' 
matter is smaller. It would seem that the deposition of the fat compresses and 
causes the disappearance of a portion of the vessels. In this way, when active 
nutrition is required, as in the child, there is abundance of vessels with little 
fat, while, in the aged, there is a larger proportion of fat and fewer vessels. 
This connection is observed also in disease. Thus, in osteitis, the portion of the 
bone which is red with vessels has a less proportion of fat than the other parts, 
which may possess even a larger proportion than usual. So in that singular 
change in bones termed their fatty condition, the naked eye can detect no vessels 
in the medullary substance, sufiicient of them only remaining to maintain the 
slow and incomplete nutrition of the part. 

Denying the existence of a medullary membrane, the physiological and patho- 
logical actions attributed to it must be otherwise explained. We cannot say, 
with M. Fiourens, that it effects the absorption of the inner layers of the canal, 
this being in reality accomplished by the capillary vessels supported by the 
medulla. So, too, a membrane takes no part in the formation of callus, and in 
accomplishing the various changes supervening upon osteitis ; but the material 
for all these may be amply supplied by the vascular network. — Archives Gene- 
rales, t. XX. pp. 275-74. 

[We should be disposed to regard the "gelatiniform matter'^ of these authors 
as an organizable blastema, the incipient condition of fibrous or fibro-mem- 
branous tissue.] — Brit, and For. Med.-Chirurg. Bei\, Oct. 1849. 

5. On the Mhmie Structure oftlie Papilhe and Nerves of the Tongue of the Frog and 
Toad. By Augustus Waller, M.D. — The attention of physiologists was first di- 
No. XXXVII.— January, 1850. 13 



190 ^ Progress of the Medical Sciences. [Jan. 

rected by Dr. Waller to the peculiar advantages possessed by the tongue of the liv- 
ing frog and other similar animals, for microscopic investigation, in the year 1839 ; 
and since that time he has published various observations made upon its com- 
ponent structures. By the induction of anaesthesia by means of ether or chlo- 
roform, he now removes the objections which formerly lay against the employ- 
ment of the tongue of the living frog, and is able to carry on his observations 
for several hours without any suffering to the animal, and without any alteration 
of the natural condition of the organ. We can only notice a few of the more 
interesting facts which he has in this manner been able to demonstrate. 

The fungiform papillas are described as consisting of "a circular zone of epi- 
thelian cells, containing a central area filled with coils of capillary vessels, and 
with nerve-tubules ascending and terminating abruptly amongst them ;" the 
investing membrane of this " gustatory area'' being always extremely thin. 
They are always elevated, and sometimes attached to the tongue merely by a 
slender footstalk. "Besides blood-vessels and nerves, we invariably discover in 
the interior of the fungiform papillse numerous striated muscular fibres. They 
are derived from the superficial muscular layer, which exists beneath the base- 
ment-membrane of the dorsum of the tongue, and appears to be one of the 
essential elements of the mucous tegument of that region. They run parallel 
with the vessels and nerves, to which they are external, and form a complete 
investment. After attaining nearly to the summit of the papillae, they curve 
inwards, and afterwards disappear in the surrounding tissues, apparently by 
losing their strise and sarcolemma, which are their distinctive characters. This 
mode of termination of the fibres is deserving attention, and is, I believe, the 
only instance in which the gradual transformation of the muscular element into 
any other tissue than the fibrous variety composing tendons has been discovered. '' 
Dr. Waller has noticed the existence of ciliary motion on these papillae, and its 
absence on the conical, which are destitute of muscular fibres. " The action of 
these fibres is to shorten the papilla, probably at the same time they may 
compress the vessels, regulating to some extent the current of blood, and produce 
the turgescence of these papillae which has been observed in the higher animals.'^ 
[We do not see how these two functions are compatible, a state of turgescence 
being one of erection.] "The action of the cilia is very evident while under 
experiment. It conduces to clear away foreign bodies from the surface ; to equal- 
ize the distribution of the sapid substance over them, and consequently over the 
nervous extremities ; and to promote the removal of the epithelial scales which 
are constantly being shed.'' The nerves of the fungiform papillae are described 
and figured by Dr. Waller as terminating in free extremities ; the tubule some- 
times ending in irregular points, sometimes in a club-shaped dilatation, sometimes 
in a spiral form, and sometimes " like small funnels, but most often with a kind 
of concentric mouth." [We have made many observations, after Dr. Weller's 
method, upon this point, but have not been able to satisfy ourselves of the 
accuracy of this description. Many of the appearances were quite compatible 
with the idea of a return of the nerve-tubes by loops ; in other instances, it 
seemed to us as if, though the sheath ceased, the central axis of the fibre was 
prolonged.] 

The conical papillas are described as possessing an opening at their summit, 
which " is either sharp at the edges, or anal-like, with circular lips. From above 
we see the commencement of a cavity lined with epithelium, which I have been 
able to see terminate in an infundibular canal extending towards the base of 
the papilla. These papillae generally contain no vascular capillaries within 
them. When they do exist, they never ascend to the summit of the body, but 
form a bend or loop at about the half or lower third of the height of the cone." 
The nerve-tubes are difficult to distinguish in the conical papillae, owing to the 
thickness of the epithelium ; Dr. Waller has succeeded, however, in demonstrat- 
ing that, as a general rule, "the nerve-tube runs close to the aperture of the 
papilla, around which it forms loops, after which it runs away in a wavy direc- 
tion. Often at each angle of the aperture is a nerve-loop of this kind, formed 
by separate tubes, besides others which are seen running in a meandering course, 
and crossing the former in various directions. The space inclosed by these 
nervous loops is much darker than elsewhere, as if it contained some dark 



f 



1850.] Organic Chemistry. 191 

granular matter. The tubes never appear to terminate abruptly in free ex- 
tremities." — Brit, and For. Med.-Chirurg. Rev., Oct. 1849, from Philosophical 
Transactions, 1849, Part I. 



A man ag-ed 23. 


A woman aged 18. 


- 799.03 


819.40 


- 200.97 


180.60 


1000.00 


1000.00 


- 119.611 


93.66 


2.088 


5.00 


- 67.103 ) 
5.304 J 


75.31 


6.864 


6.63 


2.938 ) 
.811 J 


2.530 


.625 


1.088 


.363 




1.296 


.602 


.077 


.080 or less, 



ORGANIC CHEMISTRY. 

6. On the Blood iil Purpura. — Dr. Parkes has published, in the Loud. Med. 
Gazette, Nov. 1848, two cases of purpura, which occurred in University College 
Hospital, and given analyses of the blood. The following are the results of his 
analysis : — 

Water, - - - - 

Solid residue, - - - 



Blood-corpuscles, 

Fibrin, - - - - 

Albumen, _ _ . 

Extractive matters, 

Salts of the serum. 

Consisting of 
Chloride of iodine, 
Chloride of potassium, - 
Phosphate of soda, 
Sulphate of soda. 
Peroxide of iron. 
Lime, - - - - 

The most important points in the first analysis seem to 'hQ, first, that there is 
a general lowering of the solid constituents of the blood ; second, that the rela- 
tive proportion of the organic materials to each other seems preserved; and, 
third, that the most striking alteration in the inorganic compounds consists in 
a marked increase in the quantity of iron. 

The urine was of high specific gravity, and carried ofi" a larger amount of 
solids than was normal. 

The treatment consisted in the administration of ten grains of nitrate of 
potash thrice daily, and the use of animal food. He was dismissed cured in 
one week. 

In the second case, the chief point of interest was the great increase of fibrin. 
As neither inflammation nor rheumatism was present, it seemed difficult, at 
first sight, to understand why there should be this increase in this case and not 
in the former. The difficulty was, however, completely explained by the pro- 
gress of the case. In other respects, the analysis agreed. The solid contents 
generally were lowered. BecquerePs average for healthy women is 208.1 ; and 
thus relatively the corpuscles would be nearly 104 in 1000 parts of blood, which 
is quite within the limits of health. The organic constituents in this case, as 
in the former, preserve their natural relation to one another, with the exception 
of the fibrin. The most marked change in the inorganic constituents is also 
in the increase of the iron. With only 95 of blood-corpuscles, it should have 
been reduced to about .4, whereas it has amounted to .602 in the 1000 parts. 
The potash was normal, and, as the patient had taken none as medicine, it is 
obvious that the appearance of purpura is not connected with a deficiency of 
this alkali in the blood. 

This patient entered the hospital on the 7th of August. She was bled on the 
following day; on the 14th, an attack of articular rheumatism commenced, 
which was doubtless connected with the excess of fibrin, found on the 8th. On 
the 26th, she left the hospital cured, both of the purpura and the rheumatism. 
The augmentation of the fibrin, so long before any local manifestation, is worthy 
of notice. 



192 Progress of the Medical Sciences. [Jan. 

In all the cases that Dr. Parkes has observed at University College Hospital, 
there has been doficiency in the quantity and want of variety in the food : but, 
from the close analogy between this disease and morbus maculosus werlliqfii 
(which he has seen in soldiers in India, who had been well nourished, and who 
were unavailingly treated with tonics, generous diet, and fresh vegetables, but 
were cured both by turpentine and by creasote), he thinks that there is some 
other cause beyond dietetic errors. 

7. Tlie Transformation of Sugar. — M. Bernard seems to have arrived at the 
conclusion that cane sugar is transformed into glucose by the action of the 
gastric juice ; but, if it be in too great a quantity to be so transformed, it passes 
into the vena portse unchanged, and undergoes its transformation into glucose 
in the liver. The functions of the liver appear, in part, at any rate, to consist 
of this formation of glucose or assimilable sugar. — La Fresse Medicale, Oct. 21. 



MATERIA MEDICA AND PHARMACY. 

8. Medicinal Wines. — Dr. Butler Lane exhibited to the South-Eastern branch 
of the " Provincial Med. and Surg. Association," at the meeting in July last, 
various specimens of his Medicinal Wines, and made some observations re- 
specting them. His proposition was to form fluid essences of most of the 
vegetable articles of the Materia Medica, by applying the process of fermenta- 
tion. He recommended the method of preparation in question as characterized 
by simplicity and utility, and possessing the following advantages : — 

1. The fermented preparations are more permanent than the infusions and 
decoctions, and at the same time more readily available. 

2. In a great measure, the wines avoid the spirituous admixture of the tinc- 
tures, which is desirable, inasmuch as alcohol is ill adapted as a menstruum 
of many of the vegetable medicinal principles, often interfering with their due 
therapeutic influence, and, moreover, the alcohol which does exist in the medi- 
cinal wines is in a condition of intimate combination, which renders it far less 
noxious than the comparatively raw state which it maintains in the tinctures. 

3. The economy of the fermented preparations is obvious, since three pounds 
of sugar, on an average, will answer the purpose of half a gallon of spirits of 
wine. 

4. The medicinal wines are more ef&cacious and agreeable than any other 
form of preparation. 

Dr. Lane recommended the process to be tried, more especially with opium, 
gentian, and senna, and gave the following directions: Either of the medicines 
is to be repeatedly macerated in hot water, until the active medicinal matter is 
judged to be extracted, and a sufficient bulk of fluid is obtained to make an in- 
fusion in the same proportional strength as the respective tinctures ; cold water 
only may be used to digest the senna if preferred, and will probably be equally 
efficient. The infusion is then to be strained off with sufiicient pressure ; but 
in respect of the opium, its entire bulk should be submitted to the fermenting 
process, with the exception of the coarse fibrous matter, which can readily be 
separated by filtering through fine canvass. In the next place, twelve ounces 
of white sugar are to be dissolved in each wine quart of the obtained watery 
extract, and the liquid being then placed in a wide-mouthed glass vessel, is to 
have a teaspoonful of good yeast added ; it is then to be lightly covered over, and 
kept in a warm room, where the temperature is pretty equable (from 60° to 70°) ; 
a high shelf in a kitchen is one of the best places which can be selected, as 
even at night more heat will be retained in the upper part of that apartment 
than elsewhere. Fermentations will progress more or less rapidly, and any 
supernatant scum may be removed from time to time. After three or four 
weeks, the intensity of the chemical action will be found to diminish materially ; 
the sweetness will have gone ofi", and a considerable sediment will have been 
thrown down. The liquid will then have assumed the vinous character, and 
should be carefully decanted and strained from the dregs ; then replaced, and 



1850.] Materia Medica and Pharmaci/. 193 

suffered to undergo further slow fermentation, as far as it is readily susceptible 
thereof, being lightly closed as before. In two or three weeks, it will become 
still and clear, and a great part of the sugar will have become converted into 
alcohol ; then, after remaining in a somewhat cooler temperature for a few days, 
the wine will be fit for bottling, care being taken that it be thoroughly fine, 
which must be effected artificially, if it have not taken place spontaneously. 

Dr. Lane then read a communication addressd to him by Mr. Allan, of Ep- 
som, who writes as follows: "I have no hesitation in saying, that I consider 
the idea of vinous preparations as likely to lead to valuable results, for which 
the profession will be under great obligations to you, I have found no difficulty 
in making the wines of senna, ipecacuanha, and opium. As far as I have tried 
them in practice, I feel assured of their efiicacy. The vinum sennge is an ele- 
gant preparation, and in general use, must soon supersede the tincture. The 
liquor opii vinosus I consider as equivalent in power and effect to Battley's 
liquor opii sedativus.^^ 

Dr. Shelley, of Epsom, in a note addressed to Dr. Lane, also writes thus: 
**I have now for a few months past used your new medicinal preparations, and 
can speak with certainty as to their manifold advantages. Their efficacy is in- 
dubitable, and in many instances they are superior to the preparations of the 
same drugs now in use. The preparation of opium you gave me is certainly a 
very valuable medicine, producing the usual narcotic effects of that drug with 
certainty, and apparently without stimulating." " The vinum gentianse, which 
I have used most extensively, is by far the best preparation of that drug which 
has yet been produced: as a stomachic tonic it stands unrivalled, producing its 
effects with astonishing certainty in a very short time after its first exhibition." 

Of the vinum sennse. Dr. Shelley also speaks most highly, as being an effica- 
cious and agreeable substitute for the ordinary black draught, and as an admi- 
rable aperient for children. — Provincial Med. and Surg. Journal, Sept. 5th, 1849. 

9. Manganese as a Sicccedaneum to Steel. — M. Hannon expresses himself as 
follows, in the Repertoire de Pharmacie: "Medicinal properties very similar 
to those of martial salts have long been conceded to manganese salts, but they 
have not as yet been tried in actual practice. The preparations of manganese 
ought to be put on the same footing as compounds of iron, for where steel fails 
manganese will often succeed. When chalybeate medicines do not cure the 
patient, they make him worse, for the globules of the blood, being overloaded 
with iron, cannot absorb any more of that metal, and the latter, under such 
circumstances, merely obstructs the digestive apparatus. Manganese is then 
wanting in the blood : administer that substance, and you will see chlorosis 
charmed away as it were." M. Hannon founds his theory, which he strengthens 
by a few cases, on the fact lately discovered by M. Millon, of iron and manga- 
nese existing simultaneously in the blood ; these metals being found in very 
small proportion in chlorotic blood. The oxide is the basis of the various 
pharmaceutical preparations recommended by M. Hannon, and a long list of 
these preparations is given in the Repertoire — viz., the sulphate, tartrate, car- 
bonate, and malate of manganese, and these are followed by such forms as 
syrup, pills, lozenges of the malate and phosphate. To give our readers an idea 
of the doses, we shall instance the pills of malate of manganese. The salt is 
prepared by pouring a solution of concentrated malic acid on carbonate of 
manganese. 

Pills of Malate of Manganese. — Take of malate of manganese fifteen grains ; 
powdered Peruvian bark, fifteen grains ; honey, sufficient to make twenty pills. 

Syrup of Iodide of Manganese. — Dissolve one drachm of carbonate of man- 
ganese in a sufficient quantity of hydriodic acid, and add to the solution about 
sixteen ounces of guaiacum and sarsaparilhi syrup. Dose, from two to six 
spoonfuls a day. We shall give publicity to the trials which our continental 
brethren are likely to make. Dr. Christison states that oxide of manganese 
has been found to act as a cumulative poison, after the manner of mercury, 
lead, and arsenic. Gmelin, says the same author, found that the sulphate in- 
creased the secretion of bile, whilst Dr. Thomson, of Glasgow, observed it to 
produce nothing else than the mild purgative effect of sulphate of magnesia. — 
Lancet, Nov. 17, 1849. 



194 Progress of the Medical Sciences. [Jan. 

10. Action of Aconitum Napellus. — M. Teissier, of Lyons, has conducted a 
series of experiments on the aconitum napellus, with the view of studying its 
stupefying and antiphlogistic actions. The stupefying action is undoubted ; it 
differs from that of morphia, the influence of which is perceptible in more or 
less relieving all kinds of pain ; aconite, on the contrary, has power only over 
special pains. This specialty of action of the aconite is one of its principal 
characters, and it results from the fact that the stupefying property of this 
medicine is only secondary: its principal, and in some sort specific, action is 
exerted on the skin ; it consists in eliminating the noxious elements from the 
vessels of that membrane, and in re-establishing its functions, when they have 
been disturbed either by the repercussion of the perspiration or by the presence 
of any virus. Thus, aconite is adapted for the treatment of diseases caused by 
cold, the consequences of catarrhs, and also of the diseases in which a morbid 
principle is retained in the cutaneous tissue, such as the exanthematous fevers. 
The painful diseases in which M. Teissier has obtained benefit from the sedative 
action of aconite, are those depending on a catarrhal or rheumatic cause. The 
antiphlogistic action of the plant is quite secondary and subordinate to its action 
on the skin. — Journ. Psychol. Med., Oct. 1849, from Bevue Medicate. 

11. Galvanic Apparatus for applying Chloride of Zinc as a Counter-irritant. — 
Dr. Thomas Smith states [Lond. Journ. of Medicine, Sept. 1849) that, for the 
last two or three 3^ears, he has been in the habit of using galvanism as a counter- 
irritant, finding it less painful than moxas, setons, issues, &c. He gives the 
following description of the apparatus he employs and his method of using it: — 

" A piece of perforated zinc is fastened or riveted to a piece of platinized silver, 
or, what will do equally as well, and which I generally use, a sixpence, shilling, 
or half-crown, according to the size required. The apparatus thus prepared is 
to be applied with the zinc surface next to the body, the' silver being uppermost; 
over this, I place a piece of spongio-piline, previously moistened in salt and 
water, and retain the whole in close apposition to the skin, by means of a few 
strips of adhesive plaster. At the expiration of every twelve hours, the battery 
should be removed and washed in salt and water, and then reapplied as before. 
At the end of twelve days, a deep white eschar is formed, from the action of 
the chloride of zinc. This may easily be detached, or allowed to slough out of 
itself, which generally happens about the fifteenth day, leaving a healthy-looking 
sore. By reversing the galvanic apparatus, that is, applying the silvered sur- 
face to the wound, it will be found to heal up quickly ; or it may be made to 
keep up a continuous discharge, by introducing split peas into the opening, or 
by dressing it night and morning with savine cerate. Where, however, time 
is an object, and it is desirable quickly to induce counter-irritation, this may 
easily and speedily be effected by first removing the cuticle, either by means of 
liquor ammonise fortissimus, or of acetum cantharidis, and then applying the 
battery to the denuded surface, and afterwards proceeding as in the former 
case. In this manner, the same effects are produced, in from four to six days, 
as would require twelve days by the other method. If the latter plan be adopted, 
it is not uncommon for the patient to complain of a gnawing pain in the part 
towards the evening of the third day, which, if not relieved, makes him restless 
and uncomfortable; a mild opiate, administered at bedtime, has generally had 
the effect of soothing the irritation, and preventing its future occurrence. In 
delicate females, where it is desirable not to create more pain than is absolutely 
necessary for the induction of counter-irritation, the first plan is decidedly 
preferable. I have observed, on three occasions, where the idiosyncracy of the 
patient had previously rendered the exhibition of opium or its preparations 
inadmissible, that, during the action of the battery, they have produced the 
most tranquillizing effects. Acting upon this inference, would it not be well, 
in such constitutions as are known to be susceptible to injurious impressions 
from a dose of any opiate, previously to irritate the cuticular surface by elec- 
tricity or galvanism ?^^ 

Dr. S. does not attach much importance to the galvanic action produced by 
the apparatus, but merely recommends it as being an excellent substitute where 
the more formidable remedies, such as potassa fusa, moxa, or the potential 



r 



1850.] Medical Pathology and Therapeutics. 195 

cautery, may be objected to on account of tlie suffering they entail, and which, 
in some constitutions, is an insuperable bar to their use. 



MEDICAL PATHOLOGY AND THERAPEUTICS, AND PRACTICAL 

MEDICINE. 

12. On the Comparative Patliology of the Different Races of Men. — M. Bou- 
DiN has for some considerable time been engaged in furnishing statistical 
proof of the erroneousness of the doctrines of acclimatization, which sup- 
pose that long residence habituates men to climates otherwise unfitted for 
them. He has brought forward, in his various communications, of which this 
forms one, ample proof of the little success and the great mortality that have 
attended the attempts at the colonization of Algeria. In the same way, the 
European has always failed in fixing himself in Egypt, and the French cannot 
propagate their race in Corsica. He pays a well-deserved compliment to the 
British government for having availed itself of a knowledge of these deleterious 
influences, in the more judicious distribution of its troops in recent times. Thus, 
by adding to the British troops auxiliaries recruited among races whose phy- 
siological and political aptitudes suited them to the respective climates, by 
selecting for the European troops serving in warm climates the most elevated 
regions, and by shortening the time of service abroad, it has effected a remark- 
able diminution of mortality — a diminution which, in the most unhealthy pos- 
sessions, has amounted even to fifty per cent. He contrasts this with the large 
mortality which still prevails among the French troops serving in analogous 
regions. The differences of the comparative mortality of the different races 
placed under different circumstances, is seen by examining that of the white 
and the negro population. Thus, while at Philadelphia the mortality of the 
whites is 24 per 1000, that of the negroes is 47 ; that of the whites 10 years old 
and upwards being, at New York, 15 per 1000, that of the negroes 26. At the 
Eastern Penitentiary, 20 per 1000 whites and 70 blacks die ; while at Weathers- 
field, the numbers are 28 and 100 respectively; and the same enormous dis- 
proportion is observed in other prisons. The great mortality is especially due 
in the negro tribes to phthisis and typhus ; while the negro is so proof agp.inst 
malaria, which carries off so many whites, that a due observation of this fact 
has enabled the British government to diminish wonderfully the mortality of 
their troops employed in the East and West Indies. In the West Indies, the 
mortality of the negro soldier, compared to the white one, is but as 40 to 78 per 
1000 ; and in Sierra Leone, it is 16 times less than that of the white. The latter 
are 160 times more fatally affected by fevers than the negro ; and it is only in 
diseases of the chest that they enjoy a somewhat greater immunity (4.9 to 6.3 
per 1000). Even in the most southern station in Europe, Gibraltar, hoAvever, 
the negro mortality (62) greatly exceeds that of the white soldiers (21.4), though 
these are also strangers to the soil — the diseases of the chest in the negro 
amounting to 43 per 1000. 

In respect to the Sepoys, their mortality, at the different stations, is three or 
four times less than that of the English soldier; and they enjoy a remarkable 
immunity from diseases of the chest and liver, but are more prone to dropsies, 
owing to the endemic prevalence of the beriberi. The mortality of the Hottentot 
soldier at the Cape is very small, half of the deaths arising from diseases of the 
digestive organs. They, too, are more prone to diseases of the chest than the 
white soldier. Many facts tend to show that the Jews, even amidst wide-spread- 
ing pestilences, have enjoyed great immunities; and that they pre-eminently 
possess the power of acclimatization. 

M. Boudin concludes the present paper with some observations on the diseases 
and mortality of the war-horse. In 1845, of an effective force of 33,618 horses, the 
French cavalry lost by death 2603, and by discharge 2511. Of an effective force 
of 41,793, in 1846, 2679 died, and 3314 were discharged. While the general loss 
by death and dismissal, in France, was 143 per 1000, it was in Algeria 240. In 
1836, the mean annual mortality was 197 per 1000 ; 126 in 1841 ; 108 in 1842 ; 



196 Progress of the Medical Sciences. [Jan. 

71 in 1843 ; 76 in 1844 ; 77 in 1845 ; and 66 in 1846— a diminution constituting 
one of the greatest triumphs achieved by the application of sound h3^gienic 
and administrative measures. How much yet remains to be done, however, is 
shown by the fact that the Prussian cavalry only loses 20 per 1000, and the French 
gendarmerie 14 per 1000. The largest mortality takes place in the finest quarter 
of the year — from April to October ; while the smallest corresponds to the cold 
season of the year — a fact chiefly attributable to the suspension of manoeuvres 
during the latter period. The most frequent causes of death, both in France 
and Algeria, are glanders and diseases of the respiratory organs. The glanders 
gives rise to ten times the mortality in Algeria to that produced in France — a 
difference, M. Boudin thinks, that may be in part explained by the fact of so 
many mules (5695, in a force of 18,538) being employed in the former country 
— the disease almost always attacking these animals in the acute form. In 1846, 
the Minister of War consulted 136 army veterinary surgeons, as to whether this 
disease is contagious. No answer was returned by 12 ; 24 were uncertain ; 36 
were non-contagionists ; and 64 contagionists, — Brit, and For. Med.-Chirurg. 
Rev., Oct. 1849, from Annales d'Hygibie, torn. xlii. pp. 38-80. 

13. Movements of tlie Respiratory Organs in Disease. — Dr. Sibson gave an 
account, illustrated by diagrams, at the meeting of the South-Eastern Branch 
of the " Provincial Med. and Surg. Association," in July last, of his investigation 
into the movements of the respiratory organs in disease : — 

In health, the inspiratory movement of the walls of the chest, during tranquil 
breathing, is only from two to six hundredths of an inch; while that of the 
abdomen is about three-tenths of an inch. 

During a deep inspiration, the expansive motion of the walls of the chest is, 
in front, about one inch ; and at the side, about two-thirds of an inch ; and that 
of the abdomen is about one inch. 

The expansion of the two sides of the chest is nearly equal ; the left side 
does not, however, expand quite so much as the right side, over the lower two- 
thirds of the chest, owing to the position of the heart. 

In those cases in which there is great obstruction to the entrance of air, 
during inspiration, through the outer air passages, as in cases of extreme nar- 
rowing of the larynx or trachea, the walls of the chest, to a greater or less ex- 
tent in proportion to the obstruction, instead of advancing during inspiration, 
actually fall backwards. The cause of this remarkable phenomenon is evident: 
the diaphragm acts with great power, and lengthens the lung, and, as air can 
only rush into the lengthened lung through the larynx, with great difficulty, 
the lungs collapse, just as a half-filled bladder collapses when it is lengthened, 
and the pressure of the atmosphere forces backwards the anterior walls of the 
chest. 

In emphysema and bronchitis, in those cases where there is an obstruction 
to the entrance of air into the air-cells through the smaller air tubes, the lower 
end of the sternum and the adjoining cartilages fall backwards during inspira- 
tion, while the upper part of the chest expands, and the diaphragm descends 
with great power. 

In pleuritis, with pleuritic effusion, the inspiratory expansion of the whole 
of the affected side of the chest is diminished, abolished, or, in some cases, 
even reversed, while that of the opposite side is throughout exaggerated. The 
inspiratory motion of the abdomen is also lessened or abolished in the affected 
side, while on the opposite side it is increased. 

When the whole of the lung is consolidated from gray hepatization, or tuber- 
culous deposit, or condensed from firm tendinous adhesions following pleuritis, 
then the expansion of the whole of the affected side is diminished, arrested, or 
reversed; while that of the healthy side is exaggerated. 

When the upper lobe is affected with phthisis, or pneumonia, or any other 
local disease, the expansion of that lobe is interfered with, and the inspiratory 
motion of the ribs over the affected lobe is diminished ; while that of the ribs 
over the opposite lobe is usually increased. 

It is not, however, alone in diseases of the upper lobe, that the motion of the 
ribs over that lobe, namely, the five superior ribs, is diminished, as the respira- 



1850.] Medical Pathology and Therapeutics. 197 

tory motion is lessened, or even arrested, when those ribs are injured or dis- 
eased, or when the intercostal muscles moving them are inflamed, or affected 
with pleurodynia, or when the motion of those rilbs would produce pain or injury 
in the adjoining scapula, shoulder-joint, or arm, when they are injured or in- 
flamed. 

When the lower lobe is the seat of pneumonia, or any other disease, the mo- 
tion of the ribs over that lobe is usually, but not in every case, diminished ; and 
the motion of the abdomen just below the ribs, on the affected side, is always 
diminished in these cases. 

When the heart is enlarged, and still more when it is adherent, there is di- 
minished motion of all the ribs on the left side, with the exception usually of 
the second and third. If there be pericarditis, the motion is still more interfered 
with, and the motion of the abdomen just below the xiphoid cartilage is also 
much affected, being in all cases lessened, and, in some extreme cases, quite 
interrupted. While the motion of the centre of the abdomen is diminished, 
that of the abdominal walls at each side is usually not affected. 

In peritonitis, if the disease be general, the abdominal motion is universally 
diminished; if it be partial, the diminution of respiratory motion is most 
marked over the immediate seat of the inflammation. 

Dr. Sibson concluded by calling attention to the value of the signs afforded 
by the modification of the respiratory movements in disease, and to the aid which 
those signs give in arriving at an accurate diagnosis. The nature of the disease 
cannot be detected by the observation of the signs just indicated, but its seat 
is at once pointed out. In those persons who are really healthy, but who imagine 
themselves to be the subjects of chest-disease, the observation of the movements 
of respiration will almost always give the satisfactory, conclusive, and very 
comfortable knowledge, that the chest is healthy. 

In general, the information as to the respiratory movements afforded by touch 
and sight is quite sufiicient, but, in cases of difficulty, the observations may be 
rendered minute and accurate by the aid of the chest measurer. — Prov. Med. 
and Surg. Journ., Sept. 5, 1849. 

14. Experimental Researches on the Action of Quinine, especially in large doses. 
— A memoir submitted to the Academy of Sciences, by M. Brecquet. Keport 
of MM. Andral, Rayer, and Lallemand. — M. Brecquet records the effects, on 
the principal organs of the animal economy, of sulphate of quinine, in doses of 
fifteen grains and upwards. His experiments have been made upon living 
animals ; to these, he adds observations on patients to whom he has administered 
the remedy in the above-named doses. 

1. Ejfects on the organs of circulation. — These were of two kinds — first, as 
regards the frequency; secondly, as regards the force of the pulsations of the 
heart. The frequency of the pulse was variously reduced from eight to forty 
beats in the minute. 

Alterations in the force of the heart's action were observed by the aid of M. 
Poisseuille's hgemadynamometer applied to the carotid artery of animals, in 
whom, at the same time, solution of sulphate of quinine was injected into the 
left jugular vein. Varying with the quantity injected, the force was observed 
to be diminished from a seventh to a tenth, a fourth, a third, and a half; and, 
at last, on injecting thirty grains of the bisulphate in about four ounces of 
water, all pressure disappeared, the heart's action ceased, and instant death by 
syncope ensued. These effects were observed to follow regularly, whether the 
quinine were administered by injection into the vessels, by the stomach, or by 
insertion into the cellular tissue. 

2. On the nervous centres. — Injected directly towards the brain by the carotids 
or ascending aorta, great cerebral excitement and convulsions were produced. 
If the quinine reached the brain by the more indirect route of the general cir- 
culation, agitation, headache, vertigo, tinnitus aurium, paralysis of the nerves 
of the special sense, muscular twitching, and subsultus tendinum, apparent 
intoxication, then general collapse and loss of all voluntary power. Dissection 
generally disclosed great congestion of the brain and its membranes, and even 
menino-itis. 



198 Progress of the Medical Sciences. [Jan. 

3. On the organs of respiration. — No appreciable effect was observed, except 
what might be referable to the slower propulsion of the blood by the heart. 

4. On the digestive organs. — Inflammation of the mucous membrane, attended 
with its usual symptoms, though not generally of a severe character. 

5 . On the urinary apparatus. — Pain, frequent micturition, haematuria, dysuria, 
and retention have been noticed, but always in a slight degree. 

6. On the organs of generation. — Uterine hemorrhage of the female, and debility 
of the organs in the male. 

7. On the skin and subcutaneous celhdar tissue. — Numbness and coldness of 
the surface, ecchymosis and petechiae, more or less extensive. 

8. On the blood and other animal fluids. — When blood drawn from the vessels 
was placed in contact with solution of quinine, it became liquefied, and the 
globules were destroyed ; but, in order that such effects should take place in 
the living body, the presence of a much greater quantity than can be taken by 
the stomach would be required. Animals poisoned by this medicine did not 
present this liquid state of the blood, but an increase in the proportion of fibrin 
was found. No trace of quinine could be discovered in the milk or mucous 
secretions. 

The absorption and elimination of quinine, in reference to its therapeutical 
employment, were ascertained by noting the period at which a precipitate ap- 
peared in the urine, on the addition of the bi-iodide of potassium, and by obser- 
vation of the symptoms referable to the nervous system. Thus, it was observed 
that the sulphate, in doses exceeding three grains, is absorbed in from half an 
hour to two hours, and produces its physiological effects in another hour. These 
will continue for about half an hour. A dose of fifteen grains in six hours 
continues to manifest its influence for from five to six hours. Thirty grains, 
administered in two hours, produce symptoms lasting from twelve to fifteen 
hours. When the sulphate has been administered for several days, the effects 
continue many days after it has been withdrawn. The medicine is completely 
eliminated at the end of ten or twelve hours after small doses, and in about 
forty-eight or seventy-two hours after large doses. 

Women and children are more susceptible of its influence than men ; and the 
stature and strength of the individual modify its effects. Loss of blood in- 
creases also its influence, diminishing its stimulating, and increasing its depress- 
ing action. Opiates act in a similar manner, while alcoholic stimulants have a 
reverse operation. 

In reference to its therapeutic properties, M. Brecquet found that the sulphate 
is the most active of all preparations of quinine ; that the alkaloid itself has an 
action identical with the sulphate, as has also cinchonine, but that the latter is 
by one-third less powerful ; that quinoidine has the same action as quinine on 
the nervous system, but is much more irritating to the alimentary canal. 

M. Brecquet found the solution of sulphate more active by one-half than the 
same compound in the dry state. Administered by enemata, absorption was 
found to take place more rapidly than when it was given by the mouth, but the 
effects lasted a shorter time, and the alkaloid scarcely produced its physiological 
action. Employed for frictions, ointments, lotions, and other endermic methods, 
the absorption was very feeble, and no physiological action whatever could be 
traced. 

The physiological and therapeutical effects of this medicine were more regu- 
larly and powerfully obtained by its administration in repeated doses ; its exhi- 
bition, therefore, requires to be continued for a certain period. — Lond. Med. Gaz., 
Oct. 1849, from Comptes Rendus, No. 22. 

15. Vegetable Parasites in Diseases of the Human Body. — Minute vegetable 
parasites, it is well known, are often found on and within the tissues of liv- 
ing plants and animals, invertebrate and vertebrate. They are also found in 
many diseases of the human body ; and, as the recent discoveries of Messrs. Brit- 
tain and Swayne of microscopic organisms in the evacuations of cholera patients 
have given some importance to the subject, we subjoin the following table, from 
the London Journ. of Medicine (Nov. 1849), which exhibits the names of the 



1850.] 



Medical Pathology and Therapeutics. 



199 



observers and the diseases in which these cryptogamic vegetations have been ob- 
served : — 



By whom observed. 

Bennett, (John 

Hughes) . . 



Berg . . 

BOEHM . 

Busk . . 

COWDELL 

Degner . 
Farbe . 

FUCHS 

GooDSiB, (John) 
Gruby . . . 



gunsburg . 

Hannover . 



Helmbrecht 
Heusinger . 



Jenner . . 

Langenbeck 



Lebert . 

Mayer . 

(esterlen 

Rayer . 
Remak . 



Robin 



Schcenlein 
Simon 
Sluyter . 
Textor . 

VOGEL 

Walther 
Wilkinson 



In what diseases. 

Favus: coating of the tongue; 
tubercular cavities, and sputa ; 
on gums in typhus fever. 

Aphthae of children. 

Intestinal discharges of cholera 
patients. 

Vomited matter {sarcina of Good- 
sir). 

Perspiration of cholera. 

Senile gangrene. 

False membrane expelled from in- 
testine (allied to Oscillatoria). 
Crusts of porrigo lupinosa. 

Matters ejected from the stomach 
{sarcina ventriculi). 

Favus, mentagra, porrigo decal vans 
{rnicrosporium Audouini Gr.), 
porrigo scutulata; aphthae (an- 
alogous to sporotrichium) ; and 
matters ejected in case of obsti- 
nate vomiting. 

Plica Polonica. 

Diabetic urine (Torula cerevisicB) ; 
mucous membrane in typhoid 
fever, pneumonia, pleurisy, 
phthisis, delirium tremens, apo- 
plexy, diabetes, and chronic 
gastritis. 

Posterior chamber of eye. 

Blistered surfaces. 

Cholera evacuations. 

CEsophagus, and ulcers of intes- 
tines^ in a case of typhus. 

Various cutaneous eruptions ; in a 
cerebral tumour, in a boy, aged 
two years. 



Favus {Oidium Schcenleinii) ; por- 
rigo scutulata {Achorion Leberti); 
chronic ulcer of leg. 

Scrofulous affection of the ear. 
{Mucedo ?) 

Aphthae. 

Tuberculous patient. 

Tinea favosa {Achorion Schcen- 
leinii); porrigo lupinosa; caries 
of the teeth, and aphthae ; in all 
fluid dejections, however pro- 
duced ; expectorations in pneu- 
monia. 

Aphthae ; dark brown liquid from 
stomach of icteric patient, who 
presented lesions of yellow 
fever. 

Favus; porrigo lupinosa. 

Pityriasis versicolor. 
Ditto. 

Porrigo favosa; impetigo scrofu- 
losa, etc. 

Aphthae, and vomited matters. 

Viscous matter in plica Polonica. 

Uterine discharge. 



References. 
Transactions of Royal Soc. ofEdin. 
vol. XV., part ii. 1842. 

Miiller's Archiv. 1842. 

Die Kranke Darmschleimhaut des 

Asiatischen Cholera. 1838. 
Microscopical Journal. 1843. 

Medical Gazette, Sept. 25, 1849. 

Anna!. Physic. Medic. Wrateslav. 
Tentam. 28, p. 643. 

Transactions of Microscop. Socie- 
ty, vol i. 1844-5. 

Die Krankhaflen Veranderungen 
der Haut. Gcettingen : 1840. 

Edin. Med. and Surg. Journ. April 
1842. 

Comptes Rendus. 1841, '42, '43^ 
and '44. 

Archives Generales. 1842. 



Miiller's Archiv. 1845. 
Muller's Archiv. 1842. 
Valentin's Repertorium fUr Ana- 
tomic und Physiologic. 1843. 



Casper's Wochenschrift. 1842. 
De generatione mncoris in organ- 

ismoanimali. Jenae ; 1821. 
London Journ. of Med. Feb. p. 148. 
Froriep's Neue Notizen. 1839. 

Samtlicher Bericht iiber die 18te. 
Versammlung der Gesellschaft 
deutsche Naturforscher und 
Aerzter zu Erlangen, in Sep. 
1840. 

Physiol, patholog. Paris: 1845, 
torn. ii. Mem. sur la Teigne." 

Muller's Archiv. 1844. 

Medicinishe Vierteljahrschrift. 

1842. 
Journal de I'Institut. 1842. 
Medicin. Zeitung. Berlin; 1840. 
Diagnost. und Pathol. Untersuch. 

Berlin: 1845. 



Des Vegetaux qui croissent sur 
I'homme et sur Jes animaux vi- 
vants. Paris: 1847. 

Muller's Archiv. 1839. 
De veget. par. Berlin : 1847. 
Hautkrankheiten. 1848. 
Archives Generales. 1842. 

Allgemeine Zeitung. 1842. 
Miiller's Archiv. 1844. 
Lancet, Oct. 27, 1849, 



200 Progress of the Medical Sciences. [Jan. 

16. The Scrofulous Constitution — the signs hy which it is Jcnoion — the causes in 
which it originates — its effects upon families and individuals. By Dr. King. — 
The scrofulous cojistitution may be called a defective and abnormal one, con- 
sisting in an imperfect state of the vital pov\rers ; " the principle of vitality^' 
(whatever that is) causing an imperfect development of the physical structure, 
both in form and substance. There is an imperfect deposit of bony matter to 
form the skeleton, and too great a proportion of animal matter. The bones 
are therefore too soft to hold their contents, v^hen that is required, as in the 
head ; and too soft to support weight and endure force, when that is their of- 
fice, as in the rest of the body, the spine, ribs, pelvis, and extremities. All the 
cartilaginous parts are increased in size : the extremities of the long bones are 
large and soft, and the interstices filled with serum and jelly instead of earthy 
matter : and the bones are either longer or shorter than the average. 

The head bones being soft, give way to the pressure of the brain, which is 
affected more by the influence of gravity than its own vitality, and becomes 
misshapen. When fluid collects within, the shape is still more affected, and 
in those who recover, the disfigurement remains for life. 

The malar bones are often too prominent, and the lower jaw too large: the 
palate is often imperfect, and the dentition is tardy, difficult, and irritating : 
the teeth imperfectly formed, discoloured, friable, only one half enamelled, and 
readily decay : the two middle upper incisors are often unnaturally large and 
prominent ; the upper lip partakes of the imperfection of the palate, and is 
often fissured. Frequently the ears are deficient, the cochlea being wanting, 
and sometimes the internal meatus : the thorax is deficient in size, and de- 
formed in shape : the ribs bent in, the sternum protruding, and its divisions 
imperfectly united. The abdomen is too large and protuberant, from the flab- 
biness of internal parts and abnormal size of organs and mesenterical enlarge- 
ment. The bones of the spine, partaking of the deficiency of earthy matter, 
particularly of the phosphates, are too soft to support the head and chest, and 
yield as well as their ligaments. The sacrum is often pushed towards the 
pubes, producing a narrow pelvis, and consequently in females, difiicult or im- 
possible parturition : the ilia are often twisted : the arms too long or too 
short for the body, the wrists too swollen, and the hands misshapen. The 
lower extremities are too long or too short, badly supporting the trunk : the 
knees larger, the bones badly fitted to each other, forming the knock-knee, or 
the reverse ; the tibia, sometimes the femur, bending beneath its weight, and 
the feet splay-footed, or club-footed, in various degrees. 

The soft parts partake of the same want of vitality. The brain is too large 
or too small, too soft, pulpy, and heavy in its functions, and liable to effusion 
from vascular debility : though sometimes its intellectual functions are more 
active than common, this being the exception, not the rule. The nerves are 
not so defective in carrying sensations or motions, as the brain is in its func- 
tions. The vascular system is generally relaxed and weak, and what used to 
be called (for want of a better theory) leucophlegmatic : the muscular fibre is 
weak and relaxed, and wanting in tone and vigour ; the hair is generally of a 
light colour or reddish, and thin in texture, and scanty, and liable to fall off, 
independent of disease, from a low vitality : the eye has a peculiar expression, 
generally heavy, languid, inexpressive ; whilst sometimes it has an animated 
expression of a peculiar kind, known to medical men, and may be called the 
scrofulous eye ; at others, it foretells consumption, of itself. As a contrast to 
other signs of imperfection, the eyelashes are often long and beautiful. The 
stature varies from the dwarf to the apparent giant, when a boy may be 
six feet high at fifteen years of age ; but such excess in height is never accom- 
panied with corresponding muscular strength and well-developed limbs and 
features ; they are always puerile and almost effeminate. The appearance of 
the child is often that of the little old man : while the appearance of the man 
is often that of youth and boyhood without its vigour. Sometimes the child is 
fresh and plump, with embonpoint, and to the artist beautiful ; but this hj^per- 
trophy of the cellular membrane is delusive and morbid, and often accom- 
panied with organic infirmities, foretelling future disease. 

The deposit of tuberculous matter, from imperfect assimilation, is one of the 



1850.] Medical Pathology and Therapeutics^ 201 

most obvious and leading effects of the scrofulous constitution, to whicli some 
writers have improperly confined their notion of scrofula. It is only one 
effect or disease among many which arises from a common constitution. Scro- 
fula not only produces specific diseases, but modifies all which happen in the 
body in which it exists. Thus, hooping-cough, small-pox, measles, scarlet 
fever may be fatal in a scrofulous constitution, and harmless in an unscrofu- 
lous one. 

The specific diseases to which the scrofulous diathesis gives rise, are hydro- 
cephalus, tumours of the brain, tubercle, abscess, fungus, epilepsy, insanity, 
hysteria, amaurosis, cataract, deafness, otorrhoea, conjunctivitis, lippitudo, 
lupus, oz93na, coryza ; tubercular glands in the neck ; diseases of the heart 
and lungs, of the abdomen, oesophagus, stomach, bowels, pancreas, liver, kid- 
neys, bladder, uterus, mesentery, scalp, skin, joints. Many forms of indiges- 
tion, dyspepsia, mal-assimilation, anorexia, general debility, want of tone and 
power, nervous debility without organic disease, are modifications of the scro- 
fulous diathesis : so is gout. 

Scrofula is supposed to affect one-fifth of mankind : of those who are born 
scrofulous, one-half perish in infancy ; of scrofulous foetuses, one-quarter die 
in utero. Few scrofulous persons live to be married ; this seems to be the 
provision of nature to get rid of the imperfect part of her works. Louis calls 
phthisis the most relentless enemy of the human race ; but he forgets that it 
is the means of preserving purity of blood and vigour of constitution. Nature 
does not allow the direct transmission of scrofula to proceed, as a general rule, 
beyond three or four generations. It is then cut short by phthisis, or some 
other organic form of scrofula, or by abortion, or by non-conception. The fol- 
lowing principles may be laid down as true and fundamental in scrofula, the 
cases on which they are founded being omitted for brevity ; but probably every 
medical man^s experience will assent to their truth : — 

1. The grand source of the scrofulous constitution is the direct hereditary 
principle. 

2. Scrofula is hereditary in collateral branches, when latent in the direct 
line. 

3. When second marriages take place, if both parents are healthy, the chil- 
dren will be healthy ; if either parent be scrofulous, the children will be scro- 
fulous. 

4. Persons who may have been scrofulous in youth may appear to have been 
cured, and to have grown into good health, but the constitutional taint remains, 
and the children will be scrofulous. 

5. Phthisis is the most fatal form of the scrofulous constitution. Sydenham 
called it " scrofula of the lungs. '^ Portal considered that congenital phthisis 
was scrofulous. Bayle and Laennec the same. All cachexia is a form of 
scrofula. 

6. Scrofula and phthisis co-exist in the same family. More than half the 
scrofulous patients have parents or ancestors who died of phthisis. Of eighty- 
four cases of scrofula in the hospital of St. Louis, at Paris, more than half 
had phthisical parents : all the patients in that hospital who died of various 
forms of scrofula, had tubercles in the lungs. 

7. Persons who are scrofulous in childhood sometimes become stronger after 
puberty ; but the taint remains, and the children are scrofulous. The parents 
try to conceal the scrofula of their youth, which makes it difiicult for the phy- 
sician to trace the constitution of the child, unless he is clear in his general 
principles. 

8. Parents who do not appear to be scrofulous themselves, but whose bro- 
thers or sisters are so, have scrofulous children. The family taint passes 
through them to the children. Thus, scrofula, like gout, is said sometimes to 
skip a generation. 

The scrofulous constitution may be originated independent of hereditary 
taint. 

1. Syphilis is a cause of scrofula. Astruc says, when scrofula is not heredi- 
tary, it is invaria1)ly caused by syphilis. Scrofula attacked the nurse children 
(foundlings) of Montmorenci, in France ; all the nurses had syphilis ; as they 



202 Progress of the Medical Sciences. [Jan. 

were cured, the children got well. Another originating cause of scrofula is ex- 
cessive indulgence and abuse of the sexual instinct. The children of such 
parents are generally scrofulous. The parent verifies the expression in Job 
XX. 2, 11 : " Ilis bones are full of the sin of his youth." This power of early 
self-indulgence is one of the curses of hereditary wealth. 

3. Another originating cause of scrofula 18 premature indulgence of the sex- 
ual instinct, and premature marriage. If the offspring are to be healthy, strong, 
and vigorous, no man ought to marry before the age of twenty -five, or woman 
before the age of twenty-two or twenty-three. The secretion of the seminal 
fluid, like all other secretions, must be subject to laws which decide its health 
and vigour. It should not take place too early or be too frequent, and it should 
be spontaneous — i. e. the natural result of a healthy organism, not of a mere 
mental action, or effort of imagination ; there is a period of life during which 
these conditions are complied with, but before and after which they are not. 
The ancient Germans held it disgraceful to indulge the passion before the age 
of twenty. The laws of Moses contained particular restrictions on the subject : 
and it is almost needless to state that the law of Christ inculcates purity of 
mind as the grand safeguard against the abuse of this faculty. If premature 
marriages have been preceded by indulgence, they are still more unfavourable 
to the offspring ; and if by syphilis, still more so. The gradual extinction of 
the higher and aristocratic classes, by the want of direct heirs, is perhaps part- 
ly owing to these causes, engendering a scrofulous, and therefore perishable 
constitution. On the other hand, the lower classes marry early, not only from 
instinct, but also to obtain the services of a wife and companion ; the physical 
strength has been deteriorated by low diet and hard labour, and the premature 
marriage completes the inability to produce a healthy, strong, and robust off- 
spring. The labour of the peasantry is said to be two-thirds too much, and 
their food two-thirds too little ; their food, clothing, and habitations are calcu- 
lated to a minimum of sufficiency. 

4. Another originating cause of scrofula is marriage too late in life. De- 
bility in early life may, in some degree, be corrected ; that of old age cannot. 
The generative power begins to decline about the age of forty-five. Those who 
marry late in life may have one or two children strong, but every child is 
weaker than the preceding one, and the youngest are the weakest. The child 
of the old man is become a proverb for visible debility stamped upon its physi- 
ognomy. Many of them die at birth. Some are precocious in childhood, and 
then suddenly fade and become effete and stunted, like the withering and 
dropping of fresh fruit in autumn : they are born out of due season. The period 
of weak fecundity in women commences about the age of forty. After this 
time pregnancy is often a delusion, or there is an imperfect conception or mis- 
carriage, or the child perishes at birth, or, if reared, it is delicate and scrofulous. 
When marriage has not been followed by children till after several years, they 
are generally weak and scrofulous, agreeing with the age of the parents at the 
time of birth. Children born after the expectation of farther increase of family 
has ceased, are generally scrofulous. 

5. Another cause originating scrofula is disproportionate age and unequal 
vigour. When the father is younger than the mother, it may be a cause of 
scrofula. In all animals, power is the privilege of the male. The relative supe- 
riority of the man ought to be the foundation of marriage. Upon it depend 
all domestic felicity, and often its morality. The constitution of the children 
follows that of the father more than that of the mother. This is the law in the 
brute creation. The breeders of cattle set more value upon the male than the 
female. 

6. Another originating cause of scrofula is paralysis, and also epilepsy, lu- 
nacy, and other diseases of the brain. 

It may be observed that parents may be scrofulous without apparent signs ; 
the scrofula may be latent, and the children scrofulous. Parents may show no 
signs of scrofula till after they have had children, when it may begin to appear. 
In this way it may be said to skip a generation, when it is latent. During the 
wars of the French Revolution, when the conscription was at its height, France 
was so depopulated that every man capable of bearing arms was enlisted, and 



1850.] Medical Pathology and Therapeutics. 203 

even many who were incapable. None were left at home but the sick, the in- 
Irm, and those who had married at nineteen or earlier, in order to avoid the 
conscription. Hence the population was kept up by persons too infirm and 
sickly for military service, and too young to produce strong children. Thus, 
at the Restoration in 1814, it was found difficult, out of a levy of 80,000 men, 
to find 25,000 to form a corps d' elite, and it was necessary for this purpose to 
lower the standard of height. After the peace of 1814, when the conscription 
was less rigorous, the men were more robust. But the conscripts of 1836 were 
an exception, for they were born in 1816, in which year nine-tenths of the popu- 
lation suffered severely from famine. These facts are obtained from the reports 
of the French Secretary at War. The end of marriage is domestic happiness, 
and the procreation of healthy children ; and the former depends much upon 
the latter. The law is very particular about the forms of marriage, but very 
indifferent about the results. Rational marriages must rest with the parties 
themselves. Ignorance of the laws of constitutional health is one great cause 
of irrational marriages. The great motives to marriage are rank, property, 
fancy ; to these ought to be added, morals, intellect, health, Avhich are more 
important for happiness. The moralist has hitherto been too little of a physi- 
ologist. Physiology is the basis of morals as well as of health. The educator 
ought to be a physiologist as well as a moralist. It is only by the union of the 
two that the young can be judiciously trained, and prepared for real life. 
However persons may despise physiological warnings before marriage, they 
are too sensible of their value afterwards. Constitutional diseases not only 
produce unhealthy children, but often also disgust, aversion, and misery be- 
tween the parties themselves. Marriage will not strengthen a weak constitu- 
tion, as some suppose, but debilitate it still more. It is a common observation 
of females, " I have never been well since I married." Child-bearing and 
nursing demand more than a delicate and tainted constitution can bear. The 
strength gives way under the heat and burden of the day. 

I have thus endeavoured, though too briefly for the importance of the subject, 
to trace the history of the scrofulous constitution in its hereditary principles, 
direct and indirect, proximate and remote. Where it exists, it cannot be en- 
tirely eradicated. Where it does not exist, it may be originated by the vices 
and follies of men. I have considered it as the source of many diseases not 
hitherto attributed to it ; and that its best antidote would be a judicious educa- 
tion and training upon ph3^siological principles. These principles it is the aim 
and merit of medicine to diffuse among society. The medical voice reaches 
the highest and lowest ranks. Her useful and practical truths are of daily 
application, and daily disseminated by her faithful disciples, who, in the lower 
walks of the profession, ever ready by day or night at the call of distress, find 
their chief and often their only reward in the conscious exercise of the 
duties of humanity, the mens sihi conscia recti. Finally, the greatest compli- 
ment which has yet been paid to the medical profession, and its humane and 
scientific principles, is to see the whole legislature, and every populous city 
in the kingdom, resolve to adopt them as a basis of civil polity, and to carry 
them out for the health, benefit, and happiness of the poorest and largest class 
of our fellow-creatures. — Provincial Med. and Surg. Journal, Oct. 3, 1849. 

17. Progressive General Palsy. — In the Annales 3Iedico-Psychologiqu€s, M. 
LuNiER has published a paper on progressive general palsy, which he seeks to 
show may affect the sound in mind, as well as the insane. He says its nature 
was misunderstood until towards the close of the last century ; it was described 
by Haslam, Esquirol, and Georget, as a complication, or rather a termination, of 
insanity. Progressive general palsy was, for a long while, and is even now, 
regarded by many practitioners as a disease proper to the insane. Nevertheless, 
one of the earliest works published on this subject — the thesis of M. Delaye, 
which appeared in 1824 — contains a case of progressive general paley, which 
occurred in an individual whose intellect was perfectly sound. The author of 
this excellent dissertation, however, considers the case in question to be excep- 
tional, and the greater number of practitioners who have since written on the 
subject speak of it as the only case that has come to their knowledge. The 



-^ 



\ 



204 Progre&z of the Medical Sciences. [Jan. 

name of general palsy of the insane, which is used to designate the disease, 
serves to propagate and maintain the error. A few more cases, he observes, 
have since been published, illustrative of the view he takes, and he adds that, 
if we read attentively the facts brought forAvard by J. Bayle, Delaye, Calmeil, 
Foville, Deveau, Lelut, Parchappe, Wachter, Requin, &c., and the excellent 
description many of these authors have given of general palsy, it will be easy 
to recognize that this morbid state, which they have described as a symptom or 
termination of insanity, existed in many of their cases before there was any 
lesion of the intellectual faculties, and that the lesion occurred most frequently 
consecutively only, and as a complication of the paralysis. 

M. Lunier seeks to establish that progressive general palsy may be met with 
in the general hospitals, although not so frequently as in lunatic asylums ; that the 
palsy in the one case in no respect differs from that in the other ; that the lesions 
of the intellectual faculties met with in such cases do not deserve generally the 
name of insanity, but consist simply in a diminution, or an abolition, or a more 
or less complete palsy of these faculties, comparable to the palsy of motion and 
sensation ; and, finally, that progressive general palsy constitutes a special and 
clearly-defined disease, which ought to be completely separated from insanity, 
just as are epilepsy and hysteria. 

His essay is divided into three parts : the first treats of those cases in which 
the progressive general palsy has not been preceded or accompanied by insanity 
or dementia; the second describes those cases where the palsy, without having 
been preceded by lesions of the intellectual faculties, has been afterwards com- 
plicated with dementia ; and in the third will be brought forward those cases 
in which the general palsy has been, or seems to have been, preceded by mania 
or monomania, transformed or not afterwards into dementia. 

Progressive general palsy rarely reaches its second stage, or even the termi- 
nation of its first, without the occurrence of symptoms of dementia. It is only 
at the commencement of the disease that there is not found any lesion of the 
intellectual faculties. These cases are more frequently met with in private 
practice. The absence of all lesion of the intellect, at the commencement of 
general palsy, renders the diagnosis of the disease difficult. The symptoms of 
dementia are generally those first recognized by the relatives or friends of the 
patient, and when a medical man is called in, he is astonished to find the palsy 
already much advanced, and, most frequently, completely incurable. 

The first part contains the details of six cases ; in the first, that of a man 
named Lenoir, fifty-six years of age, the disease was hereditary, and the patient 
himself was subject to attacks of cerebral congestion, for which he had been in 
the habit of losing blood — a practice he had latterly neglected ; besides which, 
he had had a rather free hemorrhoidal flux, which had ceased of late. Lenoir 
presented almost all the symptoms of the first stage of progressive general 
palsy; weakness of the special sensations and of the general sensibility, hesi- 
tation in walking, diminution of the strength of the upper limbs, a slight em- 
barrassment in speaking, loss of the generative poAver, fleeting attacks of giddi- 
ness ; there was not, however, any affection of the intellectual faculties. The 
treatment consisted in the abstraction of blood, the administration of purga- 
tives, low diet, and rest. Some of the symptoms of congestion were thus 
relieved, but the palsy continued to make progress sloAvly. In the second case, 
the hereditary character of the disease was also shown, and more and more 
frequent and violent attacks of cerebral congestion were induced by the sup- 
pression of an epistaxis. The disease in this case was only commencing. The 
third case was that of a Pole, forty-three years of age, much addicted to drink- 
ing and to venery. The disease was also hereditary in this case. Eight years 
prior to coming under notice, he had had an attack of apoplexy, followed by 
hemiplegia, respecting which M. Lunier observes, it is not uncommon to see 
progressive general palsy follow hemiplegia, the result of one or more attacks 
of cerebral congestion. In such cases, the hemiplegia progressively disappears, 
but, at the end of a certain time, if the patient be carefully examined, it will 
be found that the palsy is not so clearly defined ; there are irregularities, and 
one of the limbs of the other side presents slight symptoms of I3alsy, or per- 
haps the sensibility is greater in the arm of one side and the leg of the other, 



r 



1850.] Medical Pathology and Therapeutics. 205 

or the patient sees better with one eye, and hears better with the opposite ear. 
These singular anomalies form the transition, so to say, of the hemiplegia into 
general palsy. When the paralysis begins to become general, the hemiplegia 
becomes stationary: this is one of the signs which should make us dread the 
occurrence of general palsy in the hemiplegiac ; when the general palsy is fully 
established, the hemiplegia, instead of progressing towards a cure, increases in 
intensity, and follows the progress of the general disease. In those persons in 
whom general palsy has thus succeeded hemiplegia, there is always, even in the 
third stage of the disease, a predominance of the palsy in the side primitively 
affected. The patient in the fourth instance was a young man, eighteen years 
of age, in whom the disease supervened in consequence of a fall from a height 
of several feet, on the left side of the head, by which concussion of the brain 
was caused. In this case, M. Lunier considers the immediate cause of the 
general palsy to have been acute hydrocephalus become chronic. M. Requin 
has published a case of progressive general palsy, folloAving an injury of the 
head, which ultimately terminated fatally. The autopsy disclosed evidences of 
chronic meningitis. The fifth case is one previously published by M. Brierre 
de Boismont; and the sixth is that recorded by M. Delaye, already alluded to. 

The second series of cases, in which are recorded those in which the pro- 
gressive general palsy was not preceded by insanity, but was afterwards accom- 
panied by dementia, are four in number. The complication or occurrence of 
dementia, M. Lunier regards as an almost constant symptom of the disease, 
when it has reached a certain stage, and he believes it to depend on the same 
organic cause as the lesions of motion and sensation. The first case is that of 
a woman, fifty years of age, in whom again the disease was hereditary. The 
disease advanced to the second stage, was accompanied by symptoms of de- 
mentia, and then became stationary. The second case is an instance of a pre- 
disposition to cerebral congestion, with intermittent and alternative palsy of 
the arms, consequent on hard labour, and general progressive palsy. The 
patient was affected with suicidal lypemania. The man was thirty-five years 
old. The third is an instance of general palsy in the commencement of the 
second stage. The disease was hereditary. The abuse of mercury was con- 
sidered to have had something to do in causing the disease ; but this M. Lunier 
will not admit, and seems more inclined to refer it to the abuse of tobacco. 
He says that great smokers are peculiarly predisposed to cerebral congestion, 
and consequently to general paralysis. The question he thinks worthy of fur- 
ther examination. 

In the second stage of general paralysis, and sometimes even in the third, 
the vegetative functions are generally well performed. The appetite is good, 
often even rather voracious, and the patients present some embonpoint. Ema- 
ciation, marasmus, and gangrenous spots occur later in the disease. M. Bail- 
larger was the first to point out the loss of the generative power in the com- 
mencement of the disease. M. Lunier observes that he has noticed it in several 
cases. It is a premonitory symptom of some importance, but in some cases 
there occurs a kind of venereal orgasm, which may be present, although 
rarely, even in the third stage of the disease. 

The loss of the memory is undoubtedly the beginning of dementia. It is 
often the only sign of intellectual debility that can be discovered during the 
first and even the second stage of general palsy. 

The fourth and last case in this series is one in which the disease was heredi- 
tary, and was attended by two attacks of ambitious delirium. It was ultimately 
complicated v.^ith dementia. 

The third scries in which the general paralysis was, or seemed to be, preceded 
by mania or monomania, transformed or not afterwards into dementia, consists 
uf one case only. The patient, a man fifty years of age, had a fall from a 
height of eight or ten feet, on tlie back part of his head, a few days after which 
he was admitted into the Bicetre with symptoms of mania. M. Lunier is of 
opinion that, at this time, the patient was labouring under unrecognized general 
paralysis. At the date of the report, ten years after the accident, the man did 
not present any signs of dementia. — Jouni. of Psycliol. Medicine, Oct. 1849. 
No. XXXVII.— January, 1850. 14 



206 Progress of the Medical Sciences. [Jan. 

18. Connection between Albuminous Urine and Degeneration of tlie Kidney in 
Scarlatina. — The alleged connection between albuminous urine and degeneration 
of the kidney in scarlatina has excited much interest. Dr. Newbigging, in an 
interesting paper in the Monthly Journal (Sept. 1849), states that he was at one 
time a believer in this connection, which seemed to be corroborated by the re- 
sult of Dr. Hamilton's observations on scarlet fever, as it occurred in his practice 
at Falkirk [Edin. Med. and Surg. Journ.). Dr. JSTewbigging's faith in the cor- 
rectness of this opinion has, however, undergone a material abatement in con- 
sequence of the investigations he has recently had an opportunity of making. 
These have led him to consider the anasarcous condition, which arises during 
the progress of the convalescence from scarlet fever, to be, in very many cases, 
dependent on mere functional derangements, amenable to treatment, and leaving 
the health uninjured as regards organic alteration. 

Confirmatory of this view, he mentions that, in an early stage of the disease, 
even at the time when the eruption was just declining, having instituted an 
examination of the urine, he ascertained that, in every case, the albuminous 
haze was distinctly present, and remarkably so during the progress of the de- 
squamation. That this appearance occurred without altera,tion, either in the 
specific gravity, except to a very sinail extent, or in the quantity of the secre- 
tion ; and that it continued from a period varying from four or five to ten days, 
gradually becoming less defined, and finally disappearing altogether. 

This occurred in cases in which the urine maintained its normal standard as 
to quantity, where the patients were well, and certainly unaffected by any drop- 
sical symptoms. 

These observations seem to be corroborated by the careful investigations 
made by Dr. James Begbie, and published in the Monthly Journal for January. 
His remark corresponds with Dr. Newbigging's experience, that, "if careful 
examination of the urine be instituted, albumen in small amount will be found 
to exist in every case of scarlet fever. '^ 

It is worthy of remark, that the quantity of urine voided at the period of 
desquamation is even greater than in health, although it may contain albumen; 
and this is interesting, as, in dropsy occurring, it may be subsequently in the 
same case, the amount is greatly diminished, sometimes altogether suppressed, 
so that any diminution of this secretion, without apparent increase of albumen, 
may be almost certainly considered as the forerunner of anasarca. 

These observations, although corresponding with those of Martin Solon, who 
ascertained the presence of albumen in twenty-tivo out of twenty-three cases, are 
irreconcilable with those of some other authors, more especially with Philippe, 
who states that, although the succeeding dropsy was very common in the mild 
epidemic which he witnessed, yet, in sixty cases of the disease, in which he 
tested the urine for albumen, employing for this purpose both heat and nitric 
acid, no trace of that principle was discovered. 

Dr. Scott Alison remarks, in his " Clinical Observations,''"^ that he has ob- 
served dropsy to ensue more frequently after a severe attack of scarlatina than 
when the symptoms were of a more moderate character. Also, that the urine, 
in some cases, according to his analysis, was of specific gravity 1.005, while in 
othei^'S it was as high as 1.030 ; and he is of opinion that the kidney becomes 
organically affected at an early period of the disease. From these deductions, 
it is almost unnecessary to remark that Dr. N.'s investigations, as well as those 
of others, differ essentially. Dr. N. is greatly disposed to believe that, in many 
instances, the albumen is eliminated at the kidney — not owing to any disorgan- 
ization of that viscus, but to the fact that the blood, in all eruptive diseases, 
undergoes certain changes, and that in scarlatina this is exhibited by the 
presence of albumen in the urine ; and that, in cases where the kidney is organi- 
cally affected, as, doubtless, it is occasionally, this arises from a specific inflam- 
mation of that organ. 

Dr. N. is sensible that these observations are partial and incomplete, and had 
he again an opportunity of investigating a series of cases similarly circum- 
stanced, he would, he says, avail himself of more minute analysis ; at the same 

* London Journal of Medicine, No. III., March 1849. 



1850.] Medical Pathology and Therapeutics. 207 

time, he feels disposed to draw the following conclusions from what he has 
observed : — 

1st. That in very many cases albumen appears in the urine at an early period 
in scarlatina, without other alteration of this secretion, or affection of the system 
generally. 

2d. The diminution in the. quantity of this fluid may be considered as a cer- 
tain forerunner of anasarca. 

3d. That the treatment should be strictly antiphlogistic, the diet being for 
some time carefully regulated, so as to exclude much azotized food. 

4th. That the patient, however mild his symptoms, should be confined to bed 
for several days after the eruption has declined. 

19. On Nervous or Comndsive Cough. By M. Sandras. — There are several 
species of this : 1. The patient can receive no physical or moral impression, 
without suffering from a cough almost convulsive in its character. In examin- 
ing the chest of such a person, the physician may be led into grievous error, and 
the unnecessary fear of incipient phthisis, unless he examines it on various 
occasions and under different circumstances. Patients with incipient phthisis 
also cough from the slightest cause ; but it will be generally found that in those 
cases the impression is physical, while in those we are alluding to it is oftener 
moral. 

2. Another form of cough, having some analogy to this, is observed whenever 
certain functions are brought into play, or when they are more actively exerted 
than usual. Thus, it is found in some whose meals have been too long delayed ; 
in others, as soon as they have eaten, especially if rather fxA\j. Other persons 
cannot take a little extra-muscular exertion without bringing on a tormenting 
cough of this kind. In both this and the preceding form, the cough is dry and 
capricious, exhibiting very inconstant physical signs ; but this latter form is 
somewhat more fixed in character than the first, inasmuch as, in the same per- 
son, it is always when the same function is fulfilled that it is produced ; and it 
seems, too,- to be more dependent upon disorder of the organs in connection vfith 
the exercise of whose functions it appears ; and this should be our chief guide 
for its treatment. 

3. Another cough is observed upon the slightest irritation of the bronchi 
being produced ; so that the least cold brings on a convulsive cough nearly as 
bad as that of pertussis. Sometimes, and especially in children and very young 
adults, it takes on this form at the very commencement of the cold, and retains 
it until coction is produced. Each paroxysm is accompanied by a dry, raucous 
sound, and attempts at vomiting. Sometimes it is periodical, the disease only 
gradually assuming the characters of an ordinary ripening catarrh. In other 
cases, the spasmodic character is only observed as the cough is drawing towards 
an end. Instead, however, of coction taking place, the expectoration continues 
frothy and transparent, and is only ejected by convulsive efforts and vomiting — 
the paroxysm being brought on by the slightest cause, and a state of spasmodic 
suffocation being almost induced, until a little transparent and frothy matter is 
expectorated, when all becomes quiet and normal until a new paroxysm. In 
some cases, the cough suddenly ceases, without the expectoration having under- 
gone any change ; but this is rare. The causes of this pertussoid cough are not 
of easy appreciation. At the commencement, all is like a common cold ; and it 
is the reiterated catching cold in an eminently neuropathic subject that seems 
to induce the aggravation. The prognosis, as regards immediate danger, is 
favourable ; but is more serious in respect to future consequences, owing to the 
various evil consequences which may ensue upon the congestions the paroxysms 
give rise to. The destruction of sleep and disturbance of digestion which it 
causes are other important circumstances. Among the more serious results, is 
the production of hernias and of emphysema pulmonum. The irritation of the 
glottis and larynx should be relieved by tepid aqueous or narcotic vapours, and 
by the use of demulcent emulsions with laurel-water. When the expectoration 
is difficult, syrup of poppies, with small doses of tartar emetic, should be given, 
the antimony, whether it causes vomiting or not, affording great relief So, too, 
small doses of extract of belladonna every night, or night and morning, should 



208 Progress of the Medical Sciences. [Jan. 

be given when the expectoration is somewhat modified, and in a few days the 
convulsive character of the cough usually abates. When this drug disagrees 
with the patient, it should be used endermically. 

4. This variety may be called hysterical, from its occurring in hysterical pa- 
tients. In a subject whose respiratory organs are habitually in a good condition, 
all at once an irregularly paroxysmal cough comes on, occurring at frequent 
intervals, and sometimes almost without intermission. It does not terminate 
with the expulsion of mucosities, but is either dry and objectless, or is accom- 
panied by a true phlegmorrhagia. Hysterical phenomena som.etimes precede 
or accompany the cough ; while at others it ceases instantly that these appear. 
The cough is found to get Avorse and worse, in proportion to the development 
of the hysteria ; and this without any physical explanation of its intensity. The 
pulse is not febrile, but may be irregular, and such a one as is found in nervous 
subjects. The prognosis is favourable, unless the cough is mistaken for a phleg- 
masia, and aggravated by maltreatment. The treatment is, in fact, that which 
is proper for hysteria ; but two means are especially indicated — the use of bel- 
ladonna, and the employment of baths. Belladonna, given in doses of one- 
seventh of a grain every half hour, is highly efficacious : and it is rare for five 
or six doses to be given before improvement is visible. Baths at from 84° to 89° 
act as if by enchantment ; but sometimes it is useful to give them at from 75° 
to 82° ; and this is the temperature which will in most cases prove the best, after 
the patient has already employed the higher. — Brit, and For. Med.-Chirurg. 
Rev., Oct. 1849, from Bulletin de TMrapeutique, torn, xxxvi. pp. 385-96. 

20. Neuralgia of the Penis. By Dr. Spengler. — This case occurred in a man 
aged 40, who had been recently cured of gonorrhoea, and is reported in Casper's 
Wochenschrift, No. 46, 1848. During connection with his wife for the first time 
after a cessation of ten weeks, he became the subject of intense pain in the 
glans penis, which was repeated on each repetition of intercourse. It also fol- 
lowed erection without emission. In the intervals, he was quite free from pain. 
Various methods of treatment were adopted without benefit, until Dr. Spengler 
cauterized the urethra, the repetition of which, four times, completely cured 
him. — Prov. Med. and Surg. Journ., Aug. 22d, 1849. 

21. Neuralgia of the Cervix Uteri. — According to Malgaigne, this is a fre- 
quent affection. It is combined with leucorrhoea, and with congestion of the 
08 and cervix. The characteristic symptom is the presence of a painful spot, 
generally near the anterior lip. It is also accompanied by neuralgic pains in 
the abdomen, loins, and epigastrium. His treatment consists of an incision 
into the painful spot, by which he divides the affected nerve. He states that he 
has met with great success, and the hemorrhage has in all cases been trifling. — 
Ibid. 

22. Rheumatic Diseases of the Ear. — Mr. Harvey, in a communication read to 
the " Medical Society of London'^ (Sept. 24th, 1849), said that his attenion was 
first directed to this subject by observing the effect of rheumatic inflammation on 
the tissue of the eye, and from noticing, in many cases of ear disease that came 
under his care, the presence of articular rheumatism, which influenced, either 
directly or indirectly, the disease of the ear, the relief of one, for instance, 
being followed immediately by aggravation of the other. Believing, from ob- 
servation, that many such cases were made worse, and even irremediable, by 
mistaking the cause of the disease, and by the application of stimulating reme- 
dies, he determined on investigating the subject. The result has been that, in 
a great number of cases, he has been able to trace the connection of the ear af- 
fection with rheumatism of the system generally. In the e^^e, the secondary at- 
tack has been usually found to come on after the system has been well saturated 
by the poison of the disease ; but the ear may become affected early, the parts 
first implicated, as in the eye, being the fibrous tissues, and subsequently, the 
nervous expansions. The disease exhibited itself under two forms — the acute 
or destructive, and the chronic or insidious; both, when neglected, tended to im- 
pair the sense of hearing; and the former led to the entire destruction of the 



1850.] Medical Pathology and Therapeutics, 209 

organ. The acute form generally attacked males, and was connected with articu- 
lar rheumatism ; the chronic was more frequent in females, and was associated 
with rheumatism of the muscular system. The symptoms of the acute form 
of the disease, to which the paper was restricted, are, that the attacks arc 
paroxysmal, usually following a seizure of articular rheumatism, tinnitus au- 
rium, resembling the pumping of a steam-engine or forge-bellows, and gene- 
rally a benumbed sensation over the temporal and mastoid regions. This wan 
the part chiefly implicated in the disease, which, if not speedily relieved, ended 
in exfoliation of the bone. Some cases were detailed by Mr. Harve}^ ; in one, 
the patient was a strong, robust man, in whom the attack supervene^ on a 
severe rheumatic affection of the joint, which had been treated actively. On 
the entire subsidence of the joint aifection, the left ear became the subject of 
severe pain ; there was a benumbed ser.sation over the temporal and mastoid 
processes, accompanied with a heavy, deep tinnitus. There was considerable 
tenderness over that portion of the head. The meatus was much swollen, in 
consequence of the application of hot and stimulating remedies. He had diffi- 
culty in swallowing; the left .tonsil was much enlarged. He was cupped and 
leeched over the mastoid process, and placed under the influence of mercury 
with colchicum. This was pursued for ten days : the tympanum could noAv be 
seen ; it was of a brownish-red colour, and had lost its transpa,rency. The 
pain had diminished in intensity, but the tinnitus continued; he had occa- 
sional flying pains about the joints. Pain and tenderness continued over the 
mastoid process, and though no fxuctuation could be detected, an incision was 
made over the part down to the bone. Relief followed ; he slept better. Col- 
chicum, with quinine, was given, and the patient recovered, though for twelve 
months his hearing was somewhat affected. The second case was of a similar 
character, but, owing to the obstinacy of the patient, who refused to allow of 
any incision being made over the mastoid process, the structure of the ear was 
destroyed, and the bone exfoliated, notwithstanding active and judicious means 
were used to prevent it. The third case was one associated with cardiac in- 
flammation, which ended fatally ; the disease of the ear under the treatment 
pursued in the first case was little benefited. 

In concluding his paper, the author lays great stress on the necessity of the 
incision over the seat of pain, and considers that, in the second case, that pro- 
ceeding, if adopted, would have been as beneficial as in the first. In reference 
to the action of colchicum, he says : "It appears to me that colchicum may act 
chemically by producing some change in the urinary andalvine secretions, both 
of which it tends to increase in quantity and alter in quality; and, secondl}', it 
acts particularly upon the nervous system. If given in large doses, it should 
be carefully watched as to its effects. It should not be given in a weakened 
constitution without either a tonic or an opiate, and it is better to have the 
bowels freely acted upon at first. I have found it extremely beneficial to con- 
tinue its use internally for a lengthened period, in small and repeated doses, 
in chronic affections of the ear presumed to have arisen from rheumatism. I 
have found it by no means beneficial when it produces nausea, vomiting, or 
purging, and more particularly beneficial when tlie skin secretes freely : the pre- 
parations I place most dependence upon are the wine of the seeds internally, 
and the acetous extract, combined with spermaceti, as an external application." 
The wine of colchicum was usuall}'^ administered in a bitter infusion, at first in 
doses of five or six drops, and in chronic cases the remedy was continued for a 
long period. In acute cases, half a grain of the acetous extract, with two 
grains of calomel, was given three times a-day, until ptyalism was produced. — 
London Med. Gaz., Oct. 1849. 

23. lafaiu'de Ti/phus. — Dr. Friedleben has given, in the Arcliw fur FJiysioIo- 
gische ILdlkundc, the results of his experience of four epidemics of infantik'. 
typhus: the first extending from February to April, 1844, and from July to 
August in the same year. Then in January and February, 1846, and during 
July and August of the same year. During the months of January and Feb- 
ruary, 1840, tyjdnis Avas confined almost exclusively to children, affecting the 
adult more particularly during April and May. In the course of the three 

'1 



210 Progress of the Medical Sciences. [Jan. 

years 1844, 1845, and 1846, the Doctor had under his charge 1842 children (880 
boys, and 9G2 girls), of which 98 cases were typhoid, to wit, 46 boys and 52 
girls. Among these, only one was under one year, 23 ranged from two to five, 
32 from five to eight, 22 from eight to eleven, 12 from eleven to fourteen, and 8 
above fourteen. The endemic, therefore, fell with its greatest force on children 
between the second and eleventh years ; and was more prevalent in winter and 
summer than in the autumn and spring. 

The pathological character of this disease is detailed with great fidelity, and 
all the organic derangements of the intestinal canal, the lymphatic glands, the 
liver, the spleen, the kidneys, as well as of the circulating and respiratory sys- 
tem, and of the brain, are faithfully described. 

The glands of Peyer were much swollen ; some of them being a line and a 
half in thickness. The swelling was not, however, always uniform, — the cen- 
tre being frequently more elevated than the margins. Their surface was un- 
equal, owing to the presence of capsules, which gave them the appearance of 
ulceration. The number of the diseased glands varied from six to twenty. 
They were of a bluish-livid tint, soft, and easily detached. No change seemed 
to have occurred in the other coats of the intestine, with the exception of the 
subglandular cellular tissue, which presented the appearance of softening. 
Such were the appearances noticed in cases which proved fatal before the 
twenty-third day. When disease was protracted beyond that period, induration 
of the glands occurred. 

According to the opinion of the author, all the glands which became de- 
veloped before the twenty-first day were the soft; those later, the hard. His 
observations establish the views of MM. Rilliet and Barthez, as also those of 
Barrier, on the progress of inflammation of the glands. Severe ulceration of 
these may occur in exceedingly young subjects ; they were witnessed in a case 
only two years and a half old. They may take place at a very early period, 
even on the eighth day, but cicatrization does not Ijegin before the twenty-first 
day; its progress is found to be more rapid than in adults. 

The mucous membrane is usually sound, being changed in appearance 
only in the immediate vicinity of the glands. In one instance, the mucous 
membrane of the stomach was observed to be inflamed. The sub-mucous cellu- 
lar tissue was always natural. Changes are invariably discovered in the mesen- 
teric glands ; they are usually red and swollen, particularly at the beginning 
of the disease ; infiltration and softening are rare : and, in the opinion of the 
author, the former only occurs in yqvj serious cases, where there has been dis- 
organization of the condition of the blood. 

The general conclusions are as follovvs : — 

1. The glands of Peyer, and as a consequence the mesenteric, are the local 
seat of infantile typhus. 

2. During the first three weeks there is only simple inflammation of the fol- 
licles (plaques molles). 

3. This may terminate in resolution without ulceration; when this takes 
place, it gives rise to the first form mentioned in the paper. 

4. The progress of the cicatrization of these ulcers is very rapid. 

5. When the morbid action extends beyond the twenty-first day, infiltration 
of the glands of Peyer may occur (plaques dures). 

6. The infiltration begins in the glands in the proximity of the great intestine. 

7. This leads necessarily to ulceration, constituting the second form of ulcer- 
ations. 

8. Cicatrization takes place very slowly in these last. 

9. After the twenty-first day, the two modes of ulceration may be discovered 
united together. 

10. In all the cases terminating favourably, and in the generality of those 
ending in death, the mesenteric glands are only afiected by a simple inflamma- 
tory softening. 

11. The changes of the spleen are simultaneous with those above described. 

12. All the complications which happen before the twenty-first day are of a 
very distinct inflammatory character. 

13. The chemical character of the blood agrees with that state. 



/ 



r 



1850.] Medical Pathology and Therapeutics. 211 

Hence the corollary is obvious, that infantile typhus for the first three weeks 
consists essentially in follicular inflammation of the intestines, which readily 
admits of cure, and is essentially distinguished from the tyDhus of adults. — 
Med. Times, Oct. 13th, 1849. 

24. On tlie Pneumonia of Children. By M. Valleix. — Contrary to formerly 
entertained opinions, pneumonia is a frequent disease in children ; but it is to 
speak too vaguely to treat of children in the mass, as great differences exist, 
according to their ages. We may take three periods into account: 1st, from 
birth to the second year; 2d, from two to six ; and 3d, from six to fifteen. And 
as a general statement, making allowance for even numerous exceptions, it 
may be said that the disease decreases in severity from the first to the third of 
these periods. Careful researches have proved that, during the first two years, 
pneumonia is more frequent, more dangerous, more rapid, and oftener double, 
than at any other period of life except extreme old age; and the similarity of the 
disease, at these two extreme periods of life, is, in many respects, very remark- 
able. During even the first period, the danger of pneumonia much depends 
upon the part of such period it occurs at. Whatever the state of the child^s 
health maybe, if attacked during the first month it maybe regarded as doomed 
to certain death ; and from the first to the sixth month there is little hope of 
saving it, if the attack be at all severe. From the sixth to the twenty-fourth 
month the cures become more frequent, but the prognosis is still very bad, and 
should be most guarded, until convalescence is quite complete. The general 
symptoms may seem to amend, and the local ones to make little progress, but 
in from twenty-four to thirty-six hours a recrudescence occurs, which proves 
rapidly fatal. If the patient continue uninterruptedly to improve during thirty- 
eight hours, the convalescence is almost always definitive. The local symptoms 
should be especially watched ; for it is not here as in adults, in whom we often 
see local symptoms continue for a considerable time after the general ones have 
diminished, without any cause for alarm. If in the infant there is not in twelve 
hours a notable improvement in the local symptoms, a fatal relapse must be 
feared. Another peculiarity is the lohidar form of the disease, usually a con- 
sequence of an already severe attack of capillary bronchitis. At this period, 
too, as in advanced age, dotihle pneumonia and pneumonia of the apex are com- 
mon. M. Valleix believes that there is some confusion in the statement of MM. 
Bailly and Legendre, that the anatomical condition of the lungs in these cases 
is due to a persistence of the foetal state ; for, although a condensed state of the 
pulmonary tissue, disappearing on insuffiation, may very often be found in very 
young infants, yet it is an error to suppose that all the cases usually described 
as infantile pneumonia are of this nature. He has, in such cases, met with even 
a denser hepatization than in the adult, the lung rapidly sinking in water, and 
being quite impervious to insufiiation. The cases described by these writers 
would not, from their symptoms during life, be considered by good observers as 
pneumonia. 

In proportion as we approach the second J?eriod, the pneumonia loses its 
lobular character, and approaches nearer to that of the adult, while its fatality 
diminishes also. Indeed, especially during the last two or three years of this 
period, the benignity of the disease is remarkable ; and little alarm need be 
excited, except the child is already an invalid, when the supervention of 
pneumonia is exceedingly dangerous. By benignity it is not meant that the 
symptoms are slight, but that the cure is so sure ; for, in fact, the symptoms 
have a very alarming appearance, and yet, in spite of them, amendment takes 
place in from two to four days, after vfhich time the euro goes on rapidly. 

In the third ])eriod, the disease still more resembles that of the adult, and is 
still benign. A distinguishing circumstance, at some part of this period, is the 
appearance of expectoration. 

As a general rule, the younger the child the greater is the difficulty of the 
diagnosis. For auscultation, very young children should be held, by an assistant 
placing his hands under the thorax and belly, when examination can be made, 
especially as in this position the child usually ceases crying for awhile. Older 
children should be held on the mother's arm. In a case, in which auscultation 



212 Progress of the Medical Sciences. [Jan. 

was very difficult, M, Valleix availed himself with success of the observation of 
the increased thoracic vibration, indicated by Monneret. 

Treatment. — During the third period, the child is treated as the adult. In the 
second, we must be more chary of our means, remembering that there is a na- 
tural tendency to cure. One bleeding usually suffices, and antimony should be 
reserved only for severe cases, and used with great caution. With still greater 
caution should it ]>e given in the first period. Still, if there is great or increas- 
ing hepatization, it is to be used in divided and infrequent doses. Small cuppings 
are very preferable to leeching, and mild opiates are too much dreaded by prac- 
titioners. Blisters should be wholly discountenanced, especially in the very 
young. — Brit, and For. Med.-CJdrurg. Rev., Oct. 1849; from Bulletin de Tli6ra- 
peutique, vol. xxxvi. pp. 97-103. 

25. Tubercular Meningitis in a very young child. — Dr. Rogers exhibited to the 
Westminster Medical Society the lungs of a child, not four months old, who 
had died of tubercular meningitis (hydrocephalus acutus) ; they were infiltrated 
with tubercle in every stage and form, miliary, gray and yellow, large masses 
of which, when cut into, were found entirely softened. The bronchial glands 
were greatly enlarged, infiltrated with tubercle, and diffluent. The principal 
points of interest in history were these: mother phthisical, her relatives had 
died of phthisis. The infant, at birth, was a fine, large child, apparently healthy, 
but evidences were quickly developed of the strong constitutional taint, amongst 
which, cough, continuing during its whole life. It was vaccinated when about 
ten weeks old ; the vesicle became unusually large, and discharged an abundant 
thin serum ; there was but little febrile disturbance, yet before the vesicle had 
completed all its changes, strabismus, especially of left eye, supervened; a 
muco-purulent secretion glued both eyelids ; the child appeared, in all other 
respects, in its usual health, and continued a habit, vfhich it always had, of 
looking at the fingers of one hand. The bead affection was at once properly 
treated, and the constitution supported, but, notwithstanding, the child gradu- 
ally wasted, and died four weeks after strabismus had come on ; it lay comatose 
for one day, and convulsions ensued a few hours only before its death. Ulcer- 
ation of cornea and escape of aqueous humour occurred towards the close of its 
existence. On post-mortem examination, the brain exhibited all the appear- 
ances characteristic of miliary tubercles and puriform deposit. There were 
two ounces of serum in the ventricles; their lining diffluent; the lungs in the 
condition mentioned ; in pericardium, two drachms of fluid ; abdominal organs 
healthy ; but the mesenteric glands enlarged and tuberculous. — Lancet, Nov. 
24th, 1849. 

26. Cod Liver Oil in Phthisis. — The earliest trials of this remedy, made on 
a large scale, were those instituted at the Brompton Hospital ; where it has now 
been given in many hundred cases. The results of all these are not given, but 
its effects are shown in 542 cases. 

Of these 542 cases, 293 were in the first stage of the disease, and 249 in the 
second and third, or those stages subsequent to softening. Of those in the first 
stage, 190 were males, and 103 were females ; 72 per cent, of the males, and 62 
per cent, of the females, had their symptoms materially improved ; in nearly 18 
per cent, of the males, and in 28 per cent, of the females, the disease was arrested 
(the term arrest implies that all, or nearly all, the symptoms of the disease had 
disappeared, the patients felt themselves Avell, and able to pursue their ordinary 
occupations) ; in 10 per cent, of the males, and in nearly 10 per cent, of the fe- 
males, the disease progressed unchecked. Of the 249 patients in the second stage 
of the disease, 139 were males, and 110 females ; in 53 per cent, of the males, the 
symptoms were materially improved, and in nearly 61 per cent, of the females; 
in a little more than 14 per cent, of the males, and in nearly 14 per cent, of the 
females, the disease was arrested. In a little more than 32 per cent, of the 
males, and in 252- per cent, of the females, the disease was not arrested. View- 
ing these results collectively, we find, in about 63 per cent., the symptoms im- 
proved ; in 18 per cent., the disease was arrested ; and in 19 per cent., it went 
on unchecked. AVhen it is recollected that, of the whole number treated at this 



1850.] Medical Pathology and Therapeutics. 213 

hospital, the disease was arrested in only 5 per cent., the value of this remedy, 
under the use of which the disease appears to have been arrested in 18 per cent, 
of the cases, must be considered very great. 

Different qualities of oil were tried, without exhibiting any marked difference 
in their remedial effects; but the oifensiveness of some of the darker kinds 
rendered their general use impracticable. The oil now used is straw-coloured, 
transparent, and free from offensive smell. Patients in general take it without 
repugnance. The dose, at first, is 1 drachm three times a-day, for an adult ; but 
it is gradually increased, in some few cases, to 1^ oz. for a dose. It is usually 
administered in camphor-water, any aromatic water, bitter infusions, milk, or 
any other agreeable fluid. When there is great irritability of stomach, it has 
been given in mucilage of gum with a few drops of hydrocyanic acid. In cases 
where there existed great anaemia and debility, and in those where the effect of 
the oil seemed slight, preparations of quinine and iron, especially the iodide, 
have been conjoined with advantage. It has appeared advantageous to intermit 
its use for a few days, when nausea and feverishness, from whatever cause pro- 
duced, are present. In certain cases, the use of the oil has been continued 
during the existence of slight hsemoptysis, without producing any injurious 
results. 

Other animal oils (not derived from the liver), and vegetable oils, were tried 
with a view of ascertaining how far their operation resembled that of cod liver 
oil. The experiments hitherto made have not shown them to possess the same 
powers ; but they have not been as yet sufficiently often repeated to warrant 
decided conclusions. 

One of the most striking effects of the use of cod liver oil is an increase in the 
patient's weight ; with a view of showing the frequency with which this occurs, 
the gain or loss of weight was ascertained in 219 cases of consumption treated 
with the oil. 

Taking both stages of the disease, and the sexes collectively, a gain of 
weight occurred in 70 per cent., a loss of weight in only 21 per cent., and in 
about 82 per cent, the weight remained stationary. The amount of the increase 
varied, being in some patients little more than one or two pounds during several 
months ; whilst, in many, the average increase was from a pound to two pounds 
weekly, during several weeks. Some very remarkable instances of great in- 
crease of weight presented themselves — thus, in one instance, 41 pounds were 
gained in 16 weeks ; in another, 19^ pounds were gained in 28 days, and 10 
pounds in the succeeding 10 days; in another case, 29 pounds were added to 
the patient's weight in 31 days. It must be observed, that an amelioration of 
the sjanptoms did not invariably follow an increase of weight, though the ex- 
ceptions were rare. An aggravation of the symptoms and a diminution of weight 
were almost invariable coincidences. In a few cases, the symptoms improved, 
though the weight remained stationar}^, or even became slightly diminished. 
In other cases, where the amelioration was still more considerable, and the 
progress of the disease appeared to have been stayed, relapse occurred, and was 
followed by a rapid progress to a fatal issue. That such cases do occur requirCvS 
to be remembered, in order to restrain too sanguine expectations, and to prevent 
the remedy from falling into the discredit which disappointment, after an un- 
limited confidence, may induce. On the other hand, without entering into a 
description of the successive steps of amelioration experienced by patients, it 
will suffice to say, that many of the cases included in the 18 per cent., in whom 
the disease is marked arrested, felt themselves as well as they had been before 
the attack of the disease. 

From these facts, no other conclusion can be drawn than that cod liver oil 
possesses the property of controlling the symptoms of pulmonary consumption, 
if not of arresting the disease, to a greater extent than any other agent hitherto 
tried. — The First Medical Report of the Hospital for Consimiption and Diseases of 
the Chest, hy the Physicians of the Institution. London, 1849. 

27. On Nux Vomica in Impotence and Spermatorrhoea. By M. Duclos. — Incom- 
plete impotence is of far more common occurrence than would be supposed, until 
many patients have been questioned respecting it. Erections are almost always 



214 Progress of the Medical Sciences. ^ [Jan. 

possible, especially in the morning ; but they are soft, incomplete, and insufficient, 
a certain amount of tension only continuing, and that for a short time. This 
state may be met with in men even of the strongest make and most robust 
constitution, in whom the vascular and muscular systems have attained their 
highest development. In others, in whom these systems and the nervous system 
are ill-developed, the generative functions are properly exercised; so that the 
general physical force is no criterion of the special force of these organs. This 
imperfect condition is as often found in those who have been excessively con- 
tinent, as in those who have abused the sexual organs ; and it is observed just 
as often in persons whose nervous system is easily excitable as in those in whom 
its lesser irritability allows of a predominance of the muscular and vascular 
systems. Self-pollution may occur either by night or by day, the discharge being 
either a true or a pseudo-spermatorrhoea. 

Accident first led the author to the employment of nux vomica in this class 
of affections; and he has since observed several cases in which its efficacy has 
proved very great. He divides 75 grains of the alcoholic extract into 100 pills. 
During 5 days, he gives one every night : then for other 5 days, 1 morning, 
2 night; for other 5 days, 2 night and morning ; and for other 5 days, 2 morn- 
ing and 3 at night ; and so on until 4 are taken night and morning. He Ijas 
never found any harm result, although some patients have taken 14 pills per 
diem. In many cases the stomach is rapidly improved by the medicine, the lost 
appetite returning. The following liniment, rubbed into the loins and on the 
inside of the thighs, is a valuable though not an essential auxiliary: R. — Tra3. 
nuc. vom. ; trae. arnic83 vel melissse, aa 60 p. tr. lyttse 15 p. The regimen 
should be tonic ; and the increased appetite demands a larger supply of food. 
A very moderate use of coitus is advisable. — Brit, and For. Med.-Chirurg. Rev., 
Oct. 1849 ; from Bull, de Therap., tom. xxxvi. pp. 529-33. 

28. Chloroform in Hydropliohia. — Mr. S. B. Denton records, in the Provincial 
Med. ayid Surg. Journal (Oct. 31, 1849), a case of hydrophobia in a boy five 
years of age. "Chloroform was perseveringly administered; but the vapour 
upon the branches of the olfjictory nerve produced such terrific fright, scream- 
ing, and convulsions,'^ that Dr. D. was glad to discontinue its use. All the 
remedies administered were without effect, and the patient died in a convulsive 
struggle. 



SURGICAL PATHOLOGY AND THERAPEUTICS, AND OPERATIVE 

SURGERY. 

29. Singular Dlstortioyi of the Loiver Extreinity svinidating Dislocation of tlie 
Thigh Bone. — Mr. Warren Finchman narrates the case of a girl, aged 11, who, 
while getting out of a railway carriage, got her leg between the carriage and 
platform. On rising, she felt pain in the hip and leg, and after a few minutes 
became unable to walk. On examination by a surgeon, nothing amiss could be 
detected, but another, under the suspicion of dislocation, caused her to be sent 
to King's College Hospital, under the care of Mr. Ferguson. She was a tall, 
healthy child. On examining the leg, it was found to be an inch and a half 
longer than the right ; the whole limb was turned outwards; there was much 
flatness over the outside of the hip, and the great trochanter seemed lower and 
less prominent than the other; there was some fulness on the inner side of the 
thigh, but the head of the femur could not be felt there, nor were the adductor 
muscles tense, and there was more motion at the hip than is usual in a case of 
dislocation. It seemed, however, to present most of the essential features of a 
case of dislocation of the femur into the foramen ovale. Accordingly, chloro- 
form was given, with a view to its reduction. It was noticed that more convul- 
sion than usual was produced by it, especially of the affected limb. AVhen the 
patient was fully under its influence, Mr. Ferguson raised the limb, and found 
that the stiffness at the joint had become quite relaxed, and, on comparing it 
with the other, that it had in every respect regained its symmetry, and this 



1850.] Surgery. 215 

without any extension having been made ; but, as she recovered from the ejffect 
of the chloroform, it again gradually resumed its unnatural appearance. Chlo- 
roform was again given, the legs again became symmetrical; a thick pad was 
placed between them, and they were tied together, but as consciousness returned, 
the injured limb was seen gradually to become elongated, and turned outwards. 
A dose of calomel, and a senna draught, with fetid, spirits of ammonia, were 
ordered. 

On the 29th, the limb retained all the appearance of dislocation, and once 
again became natural under the use of chloroform. The medicine had not 
acted, and it was found that the bowels had been much confined for some days 
past. Calomel and colocynth, with senna draughts, were given without efiect. 
On the 1st of July, Mr. Ferguson ordered half a drop of croton oil to be given 
every four hours ; no effect Avas produced. The patient remained in bed. The 
leg was not quite so much lengthened, but in other respects appeared the same; 
it ivas watched during sleep, and then retained the same position. 

On the 3d, an injection with turpentine and assafetida was given, and this 
produced copious stools, and it was now found that the aspect of the limb was 
becoming more natural. 

On the 5th and 6th, she was up and walking in the ward, and on the 8th she 
left the hospital without pain, and walking quite perfectly. — Prov. Med. and 
Surg. Journ. Oct. 17, 1849. 

30. Osseous Tumours growing from the Walls of the 3Ieatus Extermis of the 
Ear. — Mr. Joseph Toynbee relates, in the Provincial Med. and Surg. Journ. (Oct. 
3, 1849), twelve cases of osseous tumours growing from the walls of the meatus 
externus of the ear, and states that, however little it may have attracted the at- 
tention of the profession, there is reason to suppose that the growth of osseous 
tumours in the external meatus of the ear is a disease of no unfrequent occur- 
rence. Such tumours may be developed in any portion of the length of the 
tube, but the part from which they most commonly originate is about the mid- 
dle third of the passage. In one case, however, noticed below, the tumour ex- 
tended beyond the outer orifice of the osseous meatus, and could be felt by 
placing the little finger at the meatus. Occasionally, the posterior wall affords 
the point of origin to the tumour, and then it not unfrequently resembles a 
simple bulging of the wall. In other cases, a similar tumour is developed 
from the anterior part, and the two protuberances meet and lie in contact in 
the middle, leaving an inferior and superior triangular space in the place of 
the original opening of the tube. Sometimes the external surfaces of the 
tumours are in contact for nearly the entire length, and the only passage is a 
small orifice below. The tumour may also be developed from the upper sur- 
face of the tube, and by gradually increasing in size, almost or quite fill up the 
passage. Two or more tumours, again, are sometimes developed from various 
parts of the circumference of the meatus, and, converging towards the centre, 
fill up nearly the whole cavity. 

As far as my opportunities of observation during life have permitted exami- 
nation, these tumours appear to consist of extremely hard and dense bone. 
In one case, where a portion of the bone was denutied of membrane, it ap- 
peared shining, white, and polished like ivory. In another, where, under the 
misapprehension that the body was a polypus, caustic had been applied so as 
to expose the bone, the latter was found to be extremely hard and devoid of 
sensibility. In a third instance, where I observed the membrane to be absent, 
there was a thin layer of cartilage on the surface, beneath which the bone was 
very hard. 

The tumours are usually covered by the lining membrane of the meatus, 
which is frequently thick, spongy, and less sensitive than is natural. When, 
by irritation, chronic inflammation is set up, this membrane pours forth a dis- 
charge whose odour is most offensive. 

The development of these tumours is frequently unattended with any symp- 
toms calculated to attract the attention of the patient, and therefore it is only 
when by their increase of size they act as an impediment to the passage of 
sonorous vibrations to the membrana tympani, that the patient is inconve- 



216 Progress of the Medical Sciences. [Jan. 

nienced by deafness, and applies for relief. Deafness may result in these cases 
first from a collection of cerumen or epithelium lodging in, and blocking up, 
the small passage of the tube left unoccupied by the tumours ; secondly, a drop 
of water may have entered the ear during the ordinary ablutions, and produced 
the same effect ; thirdly, the growth of the tumour may have proceeded un- 
checked till the entire cavity of the meatus is filled up. In some cases, how- 
ever, the growth of the tumours produces a feeling of distension in the ear, 
and weight on that side of the head; while in others again, they appear symp- 
tomatic of, and consequent to, exostosis forming in the deeper regions of the 
ears ; as, for instance, in the tympanic or vestibular cavities — a condition 
which I have sometimes met Avith in the course of my dissections. In three of 
the cases subsequently cited, there seemed great probability of this being the 
case, and the distressing noises and sense of giddiness ma}'- probably have de- 
pended upon the pressure exerted on the expansion of the auditory nerve by 
an exostosis in the vestibule. 

The only diseased substances with which the tumours are likely to be con- 
founded are polypi; with very slight attention, however, they ma}'- readily be 
discriminated. Vv'hen inspected by means of the speculum, the polypus is 
seen to be darker in colour, and glistening, from being generally lubricated by 
discharge; the osseous tumour, on the other hand, is white, and though smooth, 
free from moisture. The base of the polypus also is generally narrow, while 
that of the osseous tumour is broad. Any doubt, however, is easily removed, 
by the use of the probe, which, being pressed against the bony protuberance, at 
once reveals its nature. 

The disease under consideration may be divided into two classes, following 
the peculiar causes which seem to influence its development. 

The first and most common class of cases is that in which the disease appears 
associated with congestion of the mucous membrane of the ear, as a result of 
rather free living. Most of the patients who have consulted me on account of 
it were in the habit of partaking freely of wine. 

The second class of cases (including the three last of those appended), 
showed symptoms indicative of disease in the cavities containing the expansion 
of the auditory nerve. 

Mr. Toynbee gives the following indications of the course of treatment to be 
pursued. In those cases, he says, where the tumours occupy a considerable 
space in the tube, deafness depending upon the occlusion of the canal by the 
accumulation cf cerumen or epithelium, it is important at once to remove past, 
and prevent future, accumulations. Where water penetrates into the orifice of 
the meatus, and fills up the only remaining pervious portion of the tube, wool 
should be placed in the orifice of the meatus when the patient is washing. 
Should the membrane covering the tumour, as is not unfrequent, be very thick, 
a certain degree of relief may be afforded by the application of remedies which 
shall reduce its substance. In one case of this kind, I was enabled to increase 
the size of the tube, and much improve the power of hearing, by applying a 
solution of nitrate of silver. 

In order to diminish the size of the tumour itself, the best remedy is that 
usually employed by surgeons in osseous growths, viz., iodine. This medicine 
I have prescribed internally, and have applied it behind the ear, and also to 
the surface of the tumours, with great advantage. In one case, a large tumour 
was so much reduced as to allow of the passage of sonorous vibrations, and 
the patient regained, in a measure, that power of hearing of which he had been 
for many months deprived. 

If further experience should establish the fact that these tumours can be ar- 
rested in their progress, especially at that early period when the area of the 
tube is but slightly diminished, much good may be accomplished, and much 
suffering relieved. And while there are many weighty objections to attempting 
the removal of these tumours by operation or by escharotics, there are none to 
the use of iodine and the other absorbent medicines, from which there is every 
prospect, by persevering use, of successful results. 



1850.] Surgery. 217 

31. Balsam of Peru as an Application to Indolent Ulcers. ~~Fi. J. Spry, in a 
communication in the Provincial Med. and Surg. Journ. (Oct. 3, 1849), states 
that he has found the balsam of Peru of very great use in several cases of in- 
dolent ulcerations of the legs and other parts of the body. Lint soaked in it 
is to be applied to the surfaces every morning, a piece of oiled silk of corre- 
sponding size is placed over this, some soft rag to fill up the hollow, and av^ell- 
applied roller over the v.hole. In one case especially, of old ulceration of 
many ^^^ears' standing, which surrounded two-thirds of the leg of a man who 
came into the infirmary for the purpose of having his leg amputated, and which, 
in the opinion of some of Mr. S.'s colleagues, could not be saved, the balsam ex- 
cited the growth of granulations over the whole surface so rapidly as to excite 
surprise, the deep sharply-defined ulcer filled up, and with a little modification of 
treatment from time to time, proceeded very fivourably to cicatrization. 

An obstinate case of lupus, or noli me tangere, was very much benefited, and 
finally healed, under similar treatment. 

32. Traumatic Tetanus, treated by Chloroform. — Mr. S. G. Sloman", of Farn- 
ham, records, in the Prov. Med. and Burg. Joium. (Sept. 5th, 1849), a case of 
traumatic tetanus in a man forty-five years of age, successfully treated by in- 
halation of chloroform. 

Mr. Dyer records, in the same journal, a case in a man forty-four years of 
age, in which the chloroform merely relieved the symptoms whilst the patient 
was under its influence, and the disease proved fatal forty-eight hours after its 
onset. 

33. — Case of Traumatic Tetanus cured by tlie Destruction of the Cicatrix by means 
of Red Hot Iron. — A robust youth, aged twenty-two years, was seizedwith trismus 
on the ninth day after the receipt of a wound on the temple, when it had almost 
healed. He experienced a painful constriction of the chest, followed by reiterated 
convulsions and opisthotonos. Suppression of urine, delirium, dysphagia, and 
unconsciousness followed. 

All other means having failed to abate the severity of the disease, M. Remy, 
on the seventh day of the attack, determined to have recourse to the mode of 
treatment advised by Larry, viz. cauterizing the cicatrix in its whole extent 
with an iron heated to a white heat. The symptoms immediately underwent 
great improvement: the convulsive movements became less frequent, and soon 
ceased entirely ; consciousness returned, and the urinar37- excretion reappeared ; 
but the muscular rigidity continued, the slightest movement or attempt at the 
deglutition of fluids produced a sense of suffocation ; the recumbent posture had 
become impossible, and the patient exclaimed against a breath of air. This 
condition, which lasted from four to five days, disappeared under the use of 
digitalis in large doses. In fifteen days more, convalescence was complete. — 
London Med. Gaz., Sept. 28th, from Comptes Reiidus, Jan. 1849. 

34. Further Observations on the Treaiment of Chronic Inflammation of the 
Bladder by Injections of Nitrate of Silver; with Cases. By R. L. MacDonnell, 
M.D. [British Am. Journ. of Med. and Phys. Sciences). — In a previous com- 
munication, noticed in our number for Oct. 1847, p. 481, Dr. MacDonnell drew 
the attention of surgeons to the great utility of injections of nitrate of silver 
into the bladder, in chronic inflammation of that organ, and in support of his 
views adduced some striking cases of its successful employment. Since the 
publication of that paper, Dr. MacD. says that he has cured a great number 
of persons afiected with this disease ; and in the present paper he gives an account 
of several cases in which the cure was effected solely l3y the injections. 

"The strength of the injection,'' Dr. MacD. says, "has seldom to be increased 
beyond five grains to the ounce, although in one instance, that of an old gentle- 
man, aged seventy-two, I had to increase the strength graducdly to ten grains 
to the ounce before a satisfactory effect was produced. It is, hovrever, always 
better to commence with a weak solution, which may be made stronger, accord- 
ing to the circumstances of each case, and the judgment of the practitioner. 
Some of my patients have hesitated about undergoing treatment by injections, 



218 Progress of the Medical Sciences. [Jan. 

in consequence of their advanced age, but though the disease is not in such 
cases so easily cured as in the young subject, it is still, in the great majority of 
instances, remediable by the same means, as was proved by the great relief ob- 
tained by a patient aged seveniy-six, who was under my care in the Montreal 
General Hospital, within the last month, into whose bladder I injected, on two 
occasions, a solution of nitrate of silver, two grains to the ounce. He left the 
Hospital of his own accord, May 23, quite free from his former complaint.'^ 

35. Femoral Hernia, operated on with success after Thirteen Days' Strangula- 
tion. — Mr. Johnston has communicated to the Monthly Journal (Nov. 1849) a 
case of this, in a woman 57 years of age, which is remarkable from the fact of 
an operation proving successful for the relief of the hernia after the contents of 
the sac had been in a state of strangulation for so long a period. The function 
of the bowel was completely arrested, but its circulation must, to some extent, 
have still been carried on. It was evidently saved from destructive constriction 
at the expense of the soft omentum, among which it was imbedded. 

36. New Operation for the Treatment of Yesico-Vaginal Fistula. — M. Jobert, 
surgeon to the Hospital St. Louis, has introduced an operation for this hitherto 
intractable accident, and which he designates "Autoplastic par glissement," 
and by which he has succeeded in effecting many perfect cures. The following 
parts or stages constitute this new operative proceeding : — 

1. The patient is placed on her back, the pelvis approached to the edge of the 
bed or table, and the thighs flexed, as in the operation for lithotomy. The walls 
of the vagina are to be separated by means of a univalve speculum and curved 
levers, contrived for the purpose. The cervix uteri is then to be laid hold of at 
the point of insertion of the vagina, by a pair of hooked forceps, furnished with 
a rack at their handles, and being drawn down to the vulvae, is maintained in 
that position during the entire operation. 

2. A semicircular incision detaches the insertion of the vagina from the cervix 
uteri. The two lips of this incision instantly separate, leaving a bleeding sur- 
face about one inch in width. The vagina, with a gliding movement, slides 
spontaneously forward, whereby the lips of the vesico-vaginal fistula are ap- 
proximated, and the loss of substance repaired. 

3. The edges of the fistula are then to be paired with a bistoury or scissors. 
The mucous membrane only is to be removed, to the extent of about one centi- 
metre, equal to one-third of an inch. It is important to remove only the mucous 
membrane, in order that further loss of substance be not incurred ; and it is 
equally important to secure a sufficiently extensive bleeding surface for subse- 
quent union. 

4. The cut edges are next to be brought together by interrupted sutures, each 
at the distance of about one-third of an inch, leaving so much of the ligatures 
as shall facilitate their removal at the proper time. 

5. If any gaping of the edges of the fistula should remain, it is also important 
to remove this by superficial incisions on either side of the fistula. 

6. Hemorrhage is to be restrained by a plug of amadou introduced into the 
vagina, and which is to be removed in a day or two, perhaps on the following 

7. An elastic catheter is to be introduced and retained m the bladder. The 
patient must maintain the recumbent posture, with the legs raised on cushions, 
until union has taken place. — Monthly l{etrosp)ect, Nov. 1849, from Bulletin de 

ThSrapeutique, Feb. 1849. 

37. Successful Case ofPuncturein Tlydroceplialus. — Mr. Kitsell communicated 
to the " Provincial Med. and Surg. Association," at their seventh anniversary 
meeting, a case of successful puncture in hydrocephalus. The subject of the 
case was his own son, noAv eighteen months of age. It was not until the child 
approached the age of eight months, that any decided symptoms of cerebral 
afi'ection manifested themselves, and even then, for some time, they were of a 
subacute character. As in most similar cases, this was preceded by symptoms 
of abdominal derangement, the dejections being variable, frequently of a gelatin- 



1850.] SiiTgery. 219 

ous appearance, and often of that light colour indicative of hepatic derange- 
ment, with paucity of urine, copious perspirations about the head and neck, 
occasional vomiting, frequent Aveak pulse, furred tongue, restlessness, loss of 
flesh, particularly of the inferior extremities, approaching a cachectic tendency, 
for which the usual remedies were applied in vain. As the symptoms gradually 
increased, the head becoming enlarged, caused separation of the parietal bones 
throughout the line of the sagittal suture, to the extent of two inches, with 
inclination of the head to the left side, which was considerably the larger, re- 
taining such inclination for nearly three weeks after the operation, the anterior 
fontanelle being extremely tense and convex, the frontal region very capacious. 

In combination with this advanced stage of the case, the symptoms assumed 
a marked character, viz., rolling of the head on the pillow, frequent tendency 
to coma, contraction of the thumbs and feet, tremulous motion of the eyelids, 
alternate flush of the cheeks, the slow pulse of compressed brain, stertorous 
breathing, dilated pupils, with strabismus, and, lastly, frequent convulsions of 
the most distressing character, numbering fourteen in thirty hours, with opis- 
thotonos, blackened countenance, foaming at the mouth, &c,, each fit threaten- 
ing the immediate extinction of life. 

After watching the little patient anxiously and almost constantly for several 
days and nights, and seeing that death appeared inevitable, Mr. K. resolved on 
puncturing the head, which operation he performed about one o'clock in the 
morning of the 6th of April last, during a convulsion, as being preventive of 
pain, the trocar being passed to the depth of two inches before any fluid es- 
caped, which he attributes in some measure to its being passed very obliquely, 
with a view to render the puncture as valvular as possible, the instrument being 
introduced about an inch below the anterior superior angle of the left parietal 
bone, in the direction of the lateral ventricle. About sixteen ounces of limpid, 
colourless fluid was speedily drawn off, which appeared to act like magic in 
subduing all the bad symptoms, no convulsion occurring afterwards. Instead 
of closing the wound with a compress and retentive bandage, Mr. K. encouraged 
the discharge of fluid by occasionally cleansing and opening the puncture, thus 
allowing it to escape, probably as fast as it was secreted, and which continued 
about five days and nights, gradually subsiding, after soaking a large number 
of napkins, the total quantity being computed at about four pints ; which slow 
discharge probably caused gradual contraction, or consent, between the con- 
taining and contained parts, so that, in all probability, no vacuum was formed, 
and the danger of suddenly removing long-continued pressure from the brain 
was in a great degree averted ; hence the happy result, which appears to have 
ended in a complete restoration to health and vigour, the head (now nearly four 
months since the operation) retaining its diminished size, the various sutures 
being closed, the anterior fontanelle much contracted and flaccid, the cerebral 
pulsations being distinctl}^ felt, and the head, which, previous to the operation, 
was nearly bald, is now thickly covered with hair. 

"Having communicated with Dr. Conquest, of London," Dr. K. sa3'S, "who 
has operated in similar cases, I have the satisfaction of stating that, after con- 
gratulating me most sincerely on the successful issue in this case, he feels 
assured that, if he had adopted my mode of procedure, he should have saved 
more children, thus intimating that a larger trocar and gradually promoting a 
discharge of the fluid, by keeping the aperture open, are essential to a success- 
ful issue.'' — Frov. Med. and Surg. Jouru., Aug. 8, 1849. 

38. Ovariotomy. — Dr. Charles Clay has lately published a volume entitled 
"The Results of all the Operations for the Extirpation of Diseased Ovaria, by 
the Large Incision, from September 12, 1842, to the present time ; to which is 
appended an Essay on the Diagnosis, Prognosis, and Treatment of Ovarian 
Disease." We have not seen this work, but extract the following statistical 
statement, with comments on the operation, from the Lond. Jouru. of Medicine, 
Sept. 1849. 

Dr. Clay gives the following tabular statement of the results of the opera- 
tion : — 



220 Progress of the Medical Sciences. [Jan, 



1 Large fieshy tuberculous tumour of the uterus 
1 Large uterine disease, combined with disease of both ovaries 
1 Large disease of one ovary, with uterine disease - 
32 Ovarian tumours ------ 

5 Exploratory incisions _ - . _ . 



Died. 


Recovered. 


1 




1 




1 




10 


22 


1 


4 



14 26 



It appears, therefore, that out of forty cases in which the section was performed, 
fourteen, or more than one-third, died: which, we consider, is an amount of 
mortality sufficient to prevent any operation from being considered legitimate, 
unless when performed for the purpose of rescuing from inevitable dea-th. 
Now, it is well known that, by means of abdominal support, ovarian dropsy 
may, in a large number of cases, be rendered only an inconvenience, and not a 
source of danger; and we think that Dr. Isaac B. Brown and others have 
shown that, by the proper application of pressure, many cures may be actually 
effected. 

Our principal objections to ovariotomy are, 1. The extreme difficulty of form- 
ing an accurate diagnosis ; 2. The occasional occurrence of spontaneous cure ; 
3. The success which has attended the treatment by pressure ; 4. The disease 
not being necessarily fatal in itself; 5, and lastly, the great mortality which 
has attended the operation, in the hands of men of undoubted skill. We will 
not go so far as to say that the operation is one which ought never to be per- 
formed ; but we do say that it ought rarely to be had recourse to, and that there 
are very few of Dr. Clay's cases in which it ought to have been attempted. In 
thus strongly denouncing ovariotomy, as a general means of treating ovarian 
tumours, we must, at the same time, state our hearty approbation of the candid 
manner in which Dr. Clay has laid the results of his experience before his pro- 
fessional brethren. Though we greatly diifer from him on the subject of ovari 
otomy, we do not the less esteem him as a worthy labourer in that department 
of science which he especially cultivates ; and to the literature of which his 
little book must be received as a valuable contribution. 

39. Multilocular Ovarian Cyst, weighing forty pounds, successfully removed by 
operation. — Mr. F. Elkington communicated an account of this case to the 
Birmingham Pathological Society. The subject of it was a dressmaker, aged 31 
years, married 15 months. 

General appeara,nce. — Tall, thin, and anj^mic. First menstruated when 17 
years of age, and continued regular and in good health till about two months 
before she was married. During the two months preceding her marriage, she 
was unwell every fortnight ; sometimes very weak, and for several days each 
time ; in fact, she was scarcely ever free from a discharge. This continued for 
six weeks after her marriage. A few weeks before, she had pain in the right 
side, "like a stitch." About three months after her marriage, she began to in- 
crease in size, and first of all in the left side. In about one month from this 
time (being four after her marriage), she increased rapidly, being " unwell" 
every week, and for five days at a time. During the last three or four months 
she has been "regular," menstruation occurring only once in the month, but 
continuing so for five days each time. The discharge was dark coloured, fre- 
quently coagulated, and smelling badly. Her general health and appetite have 
been good ; she has seldom been sick. There is no increase in the breast except 
when she is going to be "unwell." Has difficulty in making water, and passes 
but little ; bov/els regular. There is complete prolapsus uteri, which commenced 
about six months ago; at times, it is the size of her hand. Can lie on either 
side, but better on the left. When the swelling began, she could not lie on either 
side; tongue furred and swollen; pulse slow and weak. She has consulted two 
surgeons, who said she was pregnant. 

Examination of the Abdomen. — She is as large, or nearly so, as a woman at 
the full period of utero-gestation. The tumour is very movable, irregular, and 
nodulated : there is indistinct fluctuation, varying in its character at different 



1850.] Bwrgery. 221 

points. The breasts are small, and there is no areola around the nipples. The 
stethoscope being applied over the abdomen, no ''bruit" could be heard in any 
part of the tumour. 

Examination -per Vaginam. — After replacing the uterus, there could be felt no 
enlargement of that organ. 

Diag7iosis. — Ovarian tumour of the left side, of the multilocular form. She 
gradually increased in size, and about Christmas, or in January, 1849, measured 
forty-five inches round her. She now began to suffer very much from the great 
size and dragging of the tumour ; her breathing was much embarrassed. She 
was tapped February 28th, 1849. The trocar was introduced through the linea 
alba, about three inches below the umbilicus. After a quart of thick fluid 
had been drawn off, no more flowed, A probe was then passed along the canula, 
when I found that the cyst was emptied, and that the point of the probe wag 
pressing against another cyst. The trocar was again introduced, pushed 
on, and another cyst opened. At first there was scarcely any escape of fluid ; 
but, after repeatedly passing a probe along the canula, the contents of the cyst 
slowly ran off. We succeeded in drawing off about five or six gallons of thick, 
ropy, albuminous fluid. The second cyst having been emptied, it was found that 
the size of the tumour was reduced only about two-thirds, and that there were 
still several other cysts, but it was not thought advisable to empty them. In a 
few days, she was convalescent. She again very rapidly increased in size, and 
in less than a month was as large as ever. Having made up her mind to sub- 
mit to ovariotomy, I was requested to operate. She was made fully aware of 
the importance and great risk of the operation. It was performed in the pre- 
sence and with the assistance of Dr. Clay, Mr. Fletcher, Mr. Dehane, and 
several other friends. 

An incision of about twelve inches in length was made through the abdomi- 
nal parietes, and, after separating two or three slight adhesions, it was found 
necessary to diminish the size of the tumour before it could be got through the 
opening. The pedicle, which was very broad and vascular, was divided into 
two parts, and each tied with a very strong ligature. The tumour weighed 
forty pounds. She recovered rapidly ; in fact, she had not a single bad symp- 
tom. The wound was entirely healed, with the exception of the lower part, 
where the ligatures passed out, in seven days. The first ligature came away 
on the eighteenth day, and the second on the twenty-first day. She was down 
stairs a few days after, and is now to all appearances perfectly well. — Prov. 
Med. and Surg. Journal, Sept. 19, 1849. 

40. Successful Case of Ovariotomy hy the large Abdominal Section. By John 
Crouch, Esq. [Provincial Medical and Surgical Journal, Sept. 5th, 1849). — The 
subject of this case was an unmarried female 24 years of age, of "healthy 
habits and appearance/' Her abdomen first began to enlarge in 1847, and in 
May, 1849, Mr. C. drew off with a trocar seven pints of a coffee-coloured fluid, 
of a serous character, and highly charged with albumen. The irregularity of 
the tumour could now be more distinctly perceived, and on the right side of the 
umbilicus a hard, solid substance could be traced, the diameter of which was 
five or six inches from side to side, and still more than that from above down- 
wards. Of course it was impossible to ascertain the extent of the tumour 
below, as it would naturally by its own gravity descend into the cavity of the 
pelvis. The substance v/as quite movable above, except for an inch or two 
anteriorly opposite the denser part. The patient was made to lie on one side, 
and the tumour being grasped by both hands, and brought forwards from the 
spine, it was thought to communicate the feeling, that it had contracted no 
adhesions to the viscera posteriorly, and the fingers could be passed almost 
behind the cyst. 

The nature of the case having been explained to the patient, and she desir- 
ing an operation, it was performed on the 9th of July, in the following manner : — 

Having marked out with a camel-hair brush, and iodine paint, five transverse 
lines across the linea alba, for the insertion of sutures, I commenced an in- 
cision into the skin and cellular membrane, about three inches above the navel, 
No. XXXVII.— January, 1850. 15 



222 Progress of the Medical Sciences. [JaB. 

and extended it to the length of nine inches, towards the pubis, avoiding the 
umbilicus by about half an inch. I then opened the peritoneum midway be- 
tween the umbilicus and pubes to the extent of' an inch. The character of the 
tumour being now ascertained, I quickly extended the opening of the peritoneum 
to the length of the external incision. A large white cyst now partly protruded 
itself through the opening, evidently the one that had been previously tapped. 
On making an incision into it, about five pints of the same kind of cofi'ee- 
coloured fluid as before were let out : and these had collected in as many weeks. 
Four other separate cysts were then punctured, each containing from half a 
pint to a pint of fluids of different colours and consistencies. This reduced 
the tumour to about one-third of its original size, and enabled us easily to ex- 
amine its connections and the condition of the surrounding viscera. The only 
adhesion that existed was between the solid part of the tumour in front, and 
the abdominal parietes, midway between the umbilicus and the right crest of the 
ilium, to the extent of two square inches. This adhesion was easily divided 
with a blunt bone knife. A great number of small cysts were found closely 
impacted in the cavity of the pelvis ; on raising these, Dr. Surrage pronounced 
the uterus and the right ovary to be in a perfectly healthy condition. The pedicle 
of the tumour was then easily discovered, and was situated, as predicted, in 
the left broad ligament of the uterus. Its thickness, when pressed together, 
was not greater than a middle-sized finger. 

A suture-needle, armed with a double thread of very strong ligature twine,* 
was then made to pierce the centre of the pedicle near its uterine extremity, 
and the needle being cut off, two of the four ends were tied very tightly in 
opposite directions, as in the operation for the cure of a ngBvus. This was done 
in two different parts of the pedicle. Four of the eight strings were then cut 
off, and the other four were placed at the lower end of the external incision. 
The tumour was now excised. The' tying of the pedicle was the most painful 
part of the operation, and the only one of which my patient complained. 

The external incision was then accurately brought together with five inter- 
rupted sutures. To obtain this accuracy, the iodine paint lines, suggested by 
Mr. Sandford, answered remarkably well. A narrow compress of linen was 
placed on each side of the wound, and long broad straps of adhesive plaster 
were carried from the back and loins of one side over the incision, to the back 
and loins of the other side, from the epigastrium to the pubes. A roller was 
not applied around the bowels, as it was deemed inconvenient to remove, but a 
small toilet table-cloth was carefully pinned, in imitation of the " Dublin ob- 
stetric binder,'^ so as to afford equal support to the whole abdominal parietes, 
and that without the power of slipping. This application, suggested by Mr. 
T. G. Stockwell, was found very convenient and serviceable, both here and in 
the after treatment of the case. 

The whole operation occupied twenty-three minutes, and was performed with- 
out the loss of an ounce of blood. The patient was then carefully placed in 
her bed, complaining of pain in the left side only, opposite the part where the 
pedicle was tied ; pulse 80 ; skin warm and moist; no hemorrhage. A grain 
of the acetate of morphia was given in the form of a pill. 

The case progressed favourably, and by the seventeenth day the patient was 
quite well. One of the ligatures of the pedicle came away on the eighteenth, 
and the second on the nineteenth day after the operation, and the remaining 
two on the thirty-third day. 

The weight of the solid part of the cyst was nearly four pounds ; its circumfer- 
ence was not less than eighteen inches, and must have required an incision of 
nine inches for its easy removal. The fluids measured nine pints, making 
altogether, solid and fluid, nearly fourteen pounds. The number of separate 
sacs was not fewer than two hundred. The larger ones contained a serous fluid, 
like that obtained at the first tapping; some of the smaller ones were filled 
with a glairy liquid, like white of egg ; and a third set afforded a thick semi- 

* This twine was composed of a superior quality of hemp, and would support a 
weight of thirty-six pounds. 



1850.] Ophthalmology. 223 

solid substance, like dough or peas-pudding. The whole mass of cysts, when 
emptied of their contents and distended with tow, measured at its largest diame- 
ter thirty inches, and at the smaller part nearly two feet. The shape of the 
tumour is very irregular and difficult to describe. At the lower part, a mass of 
cysts projected from the rest of the tumour, forming the part which filled the 
cavity of the pelvis. Two large arteries accompanied the enlarged Fallopian 
tube to its fimbriated extremity, and then meandered over the whole cyst. 

41. Ligature of the Common Carotid for Erectile Tumour of the Face or Head. 
— In the discussion in the "Academic de Medecine," on this subject, M. Lenoir 
gave the following summary of the results of the operations which had been 
performed, viz., out of thirty-one cases in which the common carotid had been 
tied, there were eighteen cures, eight deaths, and five unsuccessful, but not fatal 
cases. M. Lenoir remarked on the necessity of making a correct diagnosis be- 
tween true erectile tumour and arterio-venous aneurism following injury. In 
this latter case, the ligature of the common carotid does no good, and the artery 
involved in the disease must be tied above and below its point of communica- 
tion with the vein. — V Union MSdicale, Nov. 3, 1849. 



OPHTHALMOLOGY. 

42. On the Treatment of Sclerotitis and Sclero-iritis by Hydriodate of Potash. 
By Robert L. MacDonnell, M. D. [British American Journ. Med. and Phys. 
Science, Nov. 1849.) — The object of this paper is to make known to the profes- 
sion the efficacy of the hydriodate of potash in the treatment of sclerotitis and 
sclero-iritis ; and the author relates several cases illustrative of its powers. 
He states that he has found it useful in syphilitic and strumous sclero-iritis ; 
and equally so in the idiopathic and rheumatic forms of the disease. But it is 
more particularly in the chronic form of sclerotitis and sclero-iritis that he has 
found the iodine useful. 

" In the administration," says Dr. MacB., "of hydriodate of potash in oph- 
thalmia, particularly when the inflammation is chiefly confined to the sclerotic, 
the same plan should be observed as when that remedy is used in inflammation 
of the fibrous membranes elsewhere, viz.: to increase the dose steadily and daily 
if necessary, until a decided impression is made upon the local disease. 

" In conclusion, I would remark that I do not claim for the hydriodate of 
potash the properties of an infallihle specific in the forms of ophthalmia alluded 
to, but I do believe most firmly that, in the great majority of cases, it will be 
found equally as useful as mercury, and not open to the objections which might 
be urged against that remedy, and much more successful than turpentine 
(which, by the by, cannot always be borne by the patient) in the very cases 
which experience proves to be the best adapted for the employment of this lat- 
ter medicine ; and, in addition, it recommends itself to our notice as a powerful 
alterative in certain states of the system, in which turpentine is useless — and 
in which mercury would be injurious. 

[Our experience in the use of the hydriodate of potash in sclerotitis and iritis, 
which has been extensive, has led us also to place much confidence in it, and we 
can confirm what Dr. MacDonnell has stated of its efficacy. We have been in 
the habit of using it in the Wills' Hospital, as well as in private practice, for 
these diseases ; and also for corneitis for several years. In the first American 
edition of " Lawrence on the Eye," published in 1843, p. 329, we have spoken 
favourably of its effects, and again in the second edition published in 1847, p. 
332.] 

43. Symmetrical Swelling of both upper Eyelids, resembling CEdema, but de- 
pending upon Fat. — Wm. Bowman, Esq., describes, in the London Journal of 
Medicine, a case of symmetrical swelling of both eyelids in a healthy-looking 
lad of 16 years of age. The swelling was precisely alike on both sides. It 



224 Progress of tlie Medical Sciences. [Jan. 

was almost limited to the outer half, or outer two-thirds of the lid, extending 
from the brow to within a sixteenth of an inch of the tarsal border, where it 
ceased by a groove, over which the relaxed and distended integument hung, as 
was very evident when the lid was viewed in profile. The swelling was reddish 
in the middle part, from fulness of the cutaneous vessels. It was quite soft, as 
if from oedema of the parts subjacent to the skin; and when pressed by the 
finger, no resistance was encountered, nor was any indentation left. The skin 
was thin, and slipped freely over the orbicularis muscle, nor was it easy to seize 
between the finger and thumb a fold of this muscular layer. When this was 
done, however, the feeling was that of redundant and loose cellular tissue be- 
neath, and not of any tumour. Eversion of the lid showed the conjunctiva and 
subjacent tissue to be perfectly natural. Pressure behind the external angular 
process detected no tumour. The globe was in all respects healthy. Careful 
inquiry as to his general functions only served to show that he was in excellent 
health. 

He stated that this swelling had come on gradually, on both sides together, 
during the preceding three months, without pain or tenderness, and that he 
was first made aware of it by the remarks of his friends. On one morning, it 
had been so much worse that he could not open the lids on waking ; but this 
had subsided during the same day, and now, for some weeks, the affection had 
been such as he then saw it. It appeared to be a symmetrical partial oedema of 
the lids, of which the cause was concealed. 

Various methods of treatment having been ineffectually tried for fifteen 
months, Mr. Bowman determined to employ a modification of the operation for 
ectropion, and to remove not merely a horizontal ellipse of integument from 
the most projecting part of the swelling, but also a corresponding portion of 
the orbicularis muscle and of the fascia below it, and so to endeavour to con- 
solidate the integuments with the parts beneath, which seemed the principal 
seat of the disease. 

On the 4th of May, Mr. B. operated on the left side. A piece of the integu- 
ment was taken up with the entropion forceps, and removed with scissors to the 
extent of two-thirds of the horizontal width of the lid, and one-third its vertical 
depth. The orbicularis thus exposed was healthy, and was removed to nearly 
the same extent, by means of common forceps and scissors ; a dense cellular 
fascia then bulged forward in the gap. This fascia being removed in its turn, 
a mass of fat, resembling the natural fat of the orbit, and about as large as an 
almond, fell forward in the opening, and Mr. B. immediately removed it. It was 
not tightly embraced by any capsule of the areolar tissue which surrounded it, 
but was divided into pellets, or small lobes, which moved freely on one another. 
It therefore had not the appearance of a fatty tumour. After its abstraction, 
there was no other tissue projecting, and he therefore closed the wound by 
sutures, and had the satisfaction of seeing it heal in four days, with an almost 
complete relief of the deformity. 

A fortnight after, at the patient's request, Mr. B. performed precisely the same 
operation on the right side, and with the same result. On cutting into the sub- 
muscular fascia, a pellet of fat appeared, and was cut away ; a lobe of what seemed 
to be lachrymal gland was then exposed to view, but, showing no disposition to 
project, it was not interfered with. When the wound healed, the deformity was 
even more completely removed than on the other side, more care having been 
taken with the shape of the piece of integument excised. Two months after- 
wards, the lids hardly bore any trace of what had occurred. 

44. Amaurosis as a Symptom of Albuminuria. — Dr. Landouzy, Professor at 
the Medical School of Rheims, in France, lately addressed a paper to the 
Academy of Sciences, wherein this physician considers amaurosis as a new 
symptom of Bright's disease. His communication terminates with the follow- 
ing conclusions: 1st. Amaurosis is almost constantly a symptom of albumi- 
nuria. 2d. This affection announces Bright's disease as an initiatory sign be- 
fore the appearance of the other symptoms. 3d. It disappears, and returns 
with the albumen in the urine. 4th. This amaurosis then forces us to consider 



1850.] Midwifery, 225 

albuminous nephritis as a result of an alteration of the ganglionic system of 
nerves. Dr. Forget, of Strasburg, published, in V Union Medicate, on the Ist 
of November, some cases confirmatory of Dr. Landouzy's views, whilst Dr. 
Levy, chief physician of the Val de Grace at Paris has brought forward three 
cases of decided albuminuria, where the amaurosis was absent. 



MIDWIFEKY. 

45. On the Mechanical Treatment of Sterility. By Henry Oldham, M.D. — 
There have been three plans of treatment of a mechanical kind, for the cure of 
dysmenorrhoea and sterility, recommended and practiced ; and it is impossible 
for any one in practice in this city [London] as an obstetrician, and who reads 
the weekly and monthly journals, to be blind to the fact, that these means have 
of late been unsparingly and boldly employed. They consist, first, of the dila- 
tation by metallic bougies or sponge tents, or by section of the os uteri internum 
and externum ; secondly, of the removal of the front or back displacement of 
the womb by Dr. Simpson's uterine stem supporter ; and, thirdly, by probing 
the Fallopian tubes. It is impossible for me to omit the notice of these expe- 
dients ; although, if the womb be ascertained to be undersized, they would, I 
should hope, be abandoned in reference to it. No cutting, or dilating, or sup- 
porting, or probing, can make a small womb larger; and the amount of uterine 
stimulus which they would excite would be considered far too unimportant to 
justify their use. I know, however, that the characters of the reduced womb 
(if I may so call it) are not always appreciated in their entirety ; and a source 
of error may arise from mistaking the natural and proportionate smallness of 
its orifice for a contraction to be removed mechanically. The anteversion I 
have noticed would, by some, be regarded as an efficient cause of sterility and 
dysmenorrhoea, and the uterine supporter be applied ; while I suppose that Dr. 
Tyler Smith, if one or both these plans had been tried and failed, would, par 
voie d'exclusion, consider it as coming within the undefined limits of tubal ca- 
theterism. The few remarks, however, which I shall make upon this subject, 
must be supposed to apply to the mechanical cure of sterility and dysmenorrhoea 
generally, without any strict application to these disorders as connected with 
the undeveloped womb. 

There are few cases which come before an obstetric practitioner which are 
so full of perplexity as those of sterility, especially where it is limited to those 
cases where the os, and cervix, and body of the uterus are free from any recog- 
nizable disease. Kecent researches have afibrded most valuable information on 
the composition of the male and female generative elements, and the physiology 
of generation ; but our knowledge of the various causes by which impregnation 
is intercepted or prevented is very limited. One of these, no doubt, is any such 
partial or complete occlusion of the sexual canals as to prevent the transmission 
of the semen. Others are to be found in imperfectly developed ova, within a 
shrunken ovary, or some defect in the semen, or a want of congruity between 
the two elements. These are subtle and concealed causes, difficult, and, with 
our present knowledge, almost impossible to detect, but of infinitely greater 
importance in their relation to primary sterility than the mechanical obstacles 
which have of late so exclusively engaged attention. It appears to me that the 
cases which justify the use of mechanical treatment require the greatest discri- 
mination, not only on account of the facility with which they may be confounded 
with perfectly natural conditions, but also because these operations are not 
without danger. There is scarcely any amount of danger or pain that women 
will not go through to obtain the prospect of becoming mothers. They are 
notoriously credulous as to success, and are the ready, and often the costly 
victims of empiricism ; and I would venture to say, that obstetricians ought to 
be nicely scrupulous in encouraging a plan of treatment of a very doubtful 
efficacy, and dangerous to life. I cannot imagine a position more overwhelm- 



226 Progress of the Medical Sciences. [Jan. 

ingly distressing to any right-minded man than to have been the means of 
destroying the life of a woman in the endeavour to remove sterility. And yet 
I am sure that, in these operations, a hazard is run quite disproportioned to the 
amount of good accomplished ; and I shall recount two fatal cases which have 
come to my knowledge : and I cannot but infer that others of a similar kind 
have occurred, but have not been recorded side by side with those of a more 
fortunate issue. 

I feel great confidence in saying that the true congenital stricture of the os 
uteri, externum or internum, or of the Fallopian tubes, sufi&cient to prevent 
impregnation, is very rarely to be met with; and yet nothing is more easy, with 
the idea of a mechanical impediment in the mind, than to be self-persuaded 
into the belief that the natural orifice is too small. It is quite impossible to 
fix a standard size for the inlet to the womb. It has often happened to me to 
feel the virgin os uteri extremely small, and yet pregnancy to take place. The 
sound, too, is a very insecure guide to the measurement of the os internum ; 
and I think it is a most reprehensible practice to allow a neuralgic dysmenor- 
rhoea, whose seat I believe is generally in the ovary, to be the indication for 
this meddlesome practice. The only cases, in my opinion, in which a mechani- 
cal dysmenorrhoea with sterility can be said to exist, are those in which the 
tissue of the cervix is large and firm, and the os uteri is diminutive in compari- 
son with the size of this body : a small, almost imperceptible, round aperture 
perforating a bulky cervix. When the tissue of the cervix is not so condensed, 
but has its normal, yielding feel, I doubt altogether the propriety of regarding 
even a very small os uteri as a strictured one. I have myself successfully 
treated by dilatation some cases of the kind above cited, but they are very feu\ 
compared with the large number which come under my care. 

I. I am indebted to my friend Dr. Golding Bird for the following instructive 
case. On April 7th, 1849, I received from him the uterus and appendages of 
a lady who had died from peritonitis, excited by attempts to cure sterility by 
mechanical dilatation, whose history, as furnished to me by Dr. Bird, is as fol- 
lows, and with whose concurrence I publish it: — 

"A lady of dark complexion, aged 36, married several years, and never preg- 
nant, resided in Jamaica. From youth she sufiered intense dysmenorrhoea, and 
always had pains during sexual intercourse. She was nervous, hysterical, and 
excitable to the last degree, and was supposed to have sufiered from every pos- 
sible form of inflammation ; these attacks obviously being neuralgic, so common 
in hysterical women. In June last, by the advice of her physician in Jamaica, 
she came to London for the express purpose of having the os uteri dilated, 
which had already been attempted by wax dilators. The obstetric physician 
who was consulted in London coincided in this opinion, and thought the sterility 
and dysmenorrhoea depended on a stricture of the os uteri. He divided the os 
uteri with a cutting instrument, and introduced silver dilators. This produced 
horrible sufiering; and, although at first she fancied the pains of menstruation 
were rather better, they soon became as bad as ever, and she did not experience 
the slightest relief. She left ofi" the treatment for a time, but was soon again 
inclined to resume it; and silver canulse were passed into the os, and left there. 
Again she sufi'ered frightfully. On Saturday, March 31st, a gentleman, the 
assistant of the physician, passed in another tube, but the distress was intole- 
rable ; and sickness and shivering coming on, she urgently begged her sister to 
try and remove it, which she succeeded in doing. Getting worse, a neighbour- 
ing surgeon was summoned, and he found her labouring under what he regarded 
as peritonitis masked by hysteria. She had scarcely any fever, collapse coming 
on almost immediately, and she continued sinking until Tuesday, when I (Dr. 

G. Bird) was summoned to her. I found her at her sister's residence at T 

Park, presenting almost the collapse of cholera: pulse 200, and a mere thread; 
distended abdomen; vomiting of black fluid; intense irritability. All treat- 
ment was useless, and she soon sunk. On examining the body, and raising 
the omentum, no appearance of disease of any kind was found above a line 
connecting the anterior superior spinous processes of the ilia. Below this line 
there was intense peritonitis ; the convolutions of the intestines covered with 



1850.] Midwifery. ^ 227 

butter-like lymph, and the pelvis filled with' pus-like fluid; the right ovary and 
broad ligament covered with the same butter-like lymph, but so feebly adherent 
that it vrashed away by dipping it in water ; the cavity of the uterus was filled 
with bloody mucus. There was no other disease." 

The uterus and appendages were examined by Dr. Oldham. 

The uterus had been opened by a single oblique division of the anterior wall, 
directed from the cervix to the left angle of the womb. The uterus was larger 
than usual for the virgin: it was rounded on its anterior surface, and a bulging 
convexity of the posterior wall, which, with the general softness of the tissue, 
showed it to have been the seat of recent engorgement. 

The blood-vessels over the entire surface of the uterus and appendages werS 
injected with blood, especially the fimbriated extremity of the tubes, the ovaries, 
the broad and round ligaments. On the anterior surface of the body of the 
uterus were two small projecting fibrous tumours, the size of a large and small 
pea; the serous investment of them was highly vascular, the blood-vessels rising 
over them just like the calyx of the ovarian ovum of the bird. There was a 
similar more flattened growth in the posterior w^all. 

The divided surface of the anterior wall showed its proper structure to be 
much enlarged (it measured in the body eight lines) ; the muscular structure 
was soft, and the veins large, a probe easily ran through tlfem. The length of 
the united cavities was two inches and .ten lines, the canal of the cervix being 
one* inch five lines. The mucous membrane of the cavity of the body was soft, 
slightly raised, and of a vermilion hue. Agitation in the water was sufficient 
to loosen and separate it. 

At the OS uteri internum, there was a zone of highly-injected blood-vessels, 
broken only at one point; the circumference of this aperture was eight lines'. 
The OS externum had a clean, smooth edge, without any break or mark of di- 
vision; its circumference measured one inch one line. The cervix had its 
characteristic markings, and the glands were empty of mucus. On the right 
side of the divided cervix, which would have formed the front wall, the ribbings 
were stretched upwards, enlarging the mesh-like appearance ; and, towards the 
OS internum, some were lacerated transversely, and from this to the os externum 
the structure was more ragged than usual. 

The right tube.—ThQ extremity of this tube was almost entirely closed as a 
congenital formation, the aperture being very small. When opened, the fimbri- 
ated end showed its characteristic rich folds of mucous membrane, which were 
much injected, and were covered with bloody mucus. The remaining two- 
thirds of the tube was apparently healthy, not vascular, and pervious through- 
out. 

The right ovary, which was almost covered with lymph, soft and large. There 
was a cyst large enough to hold a small nut on the uterine end of the ovary. 
The stroma was gorged with blood. There was only one puckered Graafian 
follicle ; the surface of the ovary was thick and corrugated. 

The left ovary was irregular in its shape, a projecting mammillary portion 
coming out from its outer end. This, on being cut into, was hard and vascular, 
like the commencement of malignant disease ; the ovarian tunic was thick and 
wrinkled ; the stroma vascular ; a few remains of Graafian vesicles, with puck- 
ered tunics, and some clots of different colours, black and brownish. 

The left tube vascular at its fimbriae, healthy in its mucous membrane, and 
its canal pervious throughout. This tube passed into the uterus more directly 
than its fellow, which was more curved. The veins healthy ; arteries healthy ; 
the right round ligament large and vascular; vagina healthy. 

It is unnecessary to comment at any length upon this case. It affords a most 
instructive example of the dangerous effects of dilatation, even in experienced 
hands, and the great caution with which it should be undertaken. It is import- 
ant, too, as showing the difficulty of detecting the cause of steriiity. I am 
sure that there was no kind of morbid contraction in this case, and that the 
OS and cervix uteri, which Avere alone treated, 'had nothing whatever to do with 
the dysmenorrhoea or sterility. Both of these, no doubt, were dependent on 
the atrophy of the ovary; and the congenital obliteration of the end of the 



228 , • Progress of the Medical Sciences. [Jan. 

right tube would have been sufficient to exclude the corresponding ovary from 
any share in the function of reproduction. 

II. Another presumed cause of sterility and dysmenorrhcea is any deviation 
in the position of the uterus, and hence an indication for the cure of these 
disorders is to replace this organ, and hold it in its proper axis in the pelvis, 
by means of Dr. Simpson's uterine supporter. Dr. Rigby and others have 
related cases of this kind. It is not necessary for me to reiterate the objections 
which I urged in the last number of the Reports upon this subject; but I cannot 
avoid relating the following case, which more than confirms my opinion of the 
gangers which may arise from this supporter. I am indebted to Mr. Bransby 
Cooper for this case, which, like the preceding one, ended fatally, and which 
he has given me his permission to publish : — 

A young married lady, of great personal attractions, was attended by Mr. 
Cooper for a very painful fissure in the anus, which he divided and speedily 
cured. She then spoke to him of what had been to her a very distressing social 
trouble, namely, her sterility, which she associated with a perfect indifference 
to sexual intercourse. Mr. Cooper examined the sexual organs ; but, as he did 
not discover any defect which could be remedied by surgery, he referred her to 
a physician-accoucli,eur. This gentleman detected the uterus- in a retroverted 
state, which he looked upon as the probable cause of the sterility. For the 
cure of this displacement, he introduced a uterine stem supporter, which set up 
peritonitis, of which she died in three days. 

It is much to be lamented that the warning which such a case as this impe- 
ratively suggests should not have been published by the obstetric physician in 
whose practice it occurred. My own opinion is that mere displacement for- 
wards or backwards, if the uterus be not diseased, does not commonly cause 
sterility ; and I cannot but characterize the practice of fixing the womb in a 
definite position by means of a stem supporter, as rash and hazardous, causing 
severe irritation and pain, and even death, to the patient, with, at the best, a 
very questionable amount of ultimate good. The anteversion or retroversion 
of a small uterus, without other complications, does not, in my experience, 
occasion any great distress ; and it is far better to leave it alone, and improve 
its tissue with the rest of the organs of the body, than to prop it up for a time 
under the feeble pretence of curing it. 

III. Dr. T. Smith's adventure of catheterizing the Fallopian tubes I know of 
only from his papers. I have the instrument by me, but at present I have no 
intention of using it. — Guy's Hosjntal Reports, Oct. 1849. 

46. Obesity, simulating Pregnancy. Caution in the Diagnosis of Pregnancy. 

By Dr. Leopold Schonburgh. — Mrs. , whose husband had been separated 

from her by imprisonment upwards of three months, after exposure to cold, 
experienced all the symptoms of pregnancy. She was a modest and virtuous 
woman, and believed herself to have been three months pregnant. In about 
eight weeks more, she believed she felt the movements of the child; the abdo- 
men continued to increase in size proportionably. At the end of nine months, 
her abdomen presented the appearance of the full period of gestation, but she 
had not felt the supposed foetal movements for several week*. The catamenia 
now returned regularly at each month ; her health was good, and the size of 
the abdomen again decreased to the size of about five months' pregnancy. The 
umbilicus was depressed, the parietes felt doughy, free from fluctuation ; the 
hands could be pressed below them four or five inches downwards towards the 
spine, and could be made to meet together beneath the fat integuments ; the 
uterus could be felt somewhat enlarged in the hypogastric region. On exami- 
nation per vaginam, the os uteri could be readily reached: it was soft, and 
seemed swollen ; two lateral cicatrices could be perceived on its surface. The 
cervix uteri' was rather more than half an inch in length. The posterior wall 
was soft, and rather tender ; pressure on the abdomen could be felt to depress 
this organ. The mucous membrane of the vagina did not present a bluish, but 
the ordinary red colour. 

It was clear that no pregnancy existed in this case, but that the suppression 



1850.] Midwifery. 229 

of the catamenia by cold had given rise to the rapid development of fat, and 
congestion of the pelvic viscera, with the consequent enlargement of the abdo- 
men. — Lond. Med. Gaz., Sept. 28, from Casper's Wochensclirift, March, 1849. 

47. Recovery of an Infant after Perforation of its Cranium. By Dr. Lagae. — 
In July, 1839, the author was called to a woman, set. 34, in labour with her 
second child. Two years before, she had been delivered of a still-born child by 
means of the forceps. He found that the labour had continued more than forty- 
eight hours, and that the practitioner already in attendance, after having in vain 
endeavoured to deliver by the forceps, had perforated the cranium, and made 
ineffectual efforts at extraction. The woman was fatigued, but not exhausted, 
and Dr. Lagae fearing, owing to the height at which the head was situated, and 
to the narrowness and obliquity of the pelvis, that greater danger would result 
to the mother by continuing the attempts at extraction than by performing the 
Caesarean section, resorted to the latter. No difficulty attended its performance, 
the mother getting about in a few weeks, and living for eight years after. A 
feeble male infant, heaving some sighs, was delivered. There was a large 
wound in its cranium, situated to the right of the sagittal suture, and a few 
lines in front of the posterior fontanelle. Through this the brain was visible, 
looking like a sanguinolent pulp, a small portion escaping by the wound, as did 
other portions, after the suppurative process was set up. The child recovered ; 
compresses, dipped in cold water, being alone applied to the part. It, now nine 
years old, was recently exhibited to the West Flanders Medical Society, a loss of 
substance equal to a two-franc piece in size being still observable in its cranium, 
notwithstanding that reparation of the loss of the cranial bones occurs in the 
young. 

The child's inteltectual faculties are in their normal state. A circumstance 
worthy of note is that, at the solution of continuity in the bone, where the soft 
parts alone cover the brain, there sometimes takes place a depression, and then 
the brain is plainly seen raised up by the arterial pulsations at the bottom of 
this cup-like depression. When this appearance manifests itself, experience 
has shown that the child is not well. At other times, the soft parts remain on 
a level with the cranial bones, and the arterial pulsations are slightly, if at all, 
observable. — Brit, arid For. Med.-Chirurg. Rev., Oct. 1849; from Revue M^dico- 
CJiirurg., tom. vi. p. 55. 

48. CcEsarean Section. — Dr. Thomas Kadford records, in tlie Prov. Med. and 
Surg. Journ. (Aug. 22d, 1849), a case of Csesarean section terminating success- 
fully, both to mother and child. The patient was thirty-one years of age, fair 
skin, and had been married nearly nine years. During this period, she has had 
five children. The labours of the first four were natural and quick ; the last 
of this number happened three years ago, and was so rapid that the infant was 
born before the obstetrician arrived. After the birth of the second, she was 
rather more delicate, and suffered a little from indigestion ; and about five or 
six years since first complained of slight rheumatic pains about her hips. Two 
years since she was confined to bed for a short time, by pains about the pelvis ; 
but she gradually recovered, and afterwards was able to walk about tolerably 
well. Her general health remained the same up to the period of her last preg- 
nancy. She was now observed to limp a little when she walked, and to be less 
in height. 

During her gestation, her progression was more difficult, and her gait more 
waddling. She also complained more of pelvic pains; and the diminution in 
her stature now evidently increased. Mollities ossium, the disease under which 
she suffered, usually commences during pregnancy, and generally becomes 
suspended in the interval, returning in an aggravated form in each successive 
pregnancy, until its ravages have completely destroyed the form of the pelvis. 
In this case, however, it did not exactly pursue this course. There is no doubt 
there existed a strong predisposition to the disease — most likely hereditary ; 
and probably the disease began at the latter part of the second pregnancy, but 
evidently no great, if any, mischief was done to the pelvis at this time, or for 



230 Progress of the Medkal Sciences. [Jan. 

a long time after this period, as the third and fourth labours were so rapidly 
and easily terminated. The rapidity of its progress is remarkable ; for there 
is little doubt that the great degree of distortion took place immediately before 
and during the last pregnancy. 

When this patient was seen by Dr. Radford, she had felt slight pains, accord- 
ing to the account of the friends, about a week ; but Mr. Cluley thought that true 
parturient pains had only existed about three days, and which were so slight 
as not to require his interference. On this day (Sunday, May 20th, 1849), at 
nine o'clock, he was again called, aiad although the pains were still trifling, he 
made an examination per vaginam, but was unable to feel either the os uteri 
or the presentation; he, therefore, had her taken out of bed and placed on the 
lap of a female friend, and again repeated his inquiry. The head of the in- 
fant was now felt, and the os uteri found dilated to the size of a half-crown 
piece. In this manner he unintentionally ruptured the membranes. The pel- 
vis, he mentioned, was considerably contracted. I found her lying on the right 
side. Pulse 120; tongue clean and moist; her countenance tranquil, but a 
little flushed. Her bowels had been freely and fully moved this morning ; and 
she had also freely and duly urinated. She was helplessly fixed on her side, 
and when requested to turn, she remarked that she suffered very great pain 
when she made an attempt to do so, or was by another person turned on the 
back. The pelvis was very considerably altered from its natural shape; its 
sides were flatter ; and the posterior division of the ilia, especially on the left 
side, projected backwards ; and the upper portion of the sacrum and the lower 
lumbar vertebras had sunk in an inward and downward direction, so that a 
great concavity was perceived here. The uterus inclined rather to the right 
side, and stood considerably more forward than usual, although it had not 
assumed the retort form to the same degree as I have witnei^sed in former cases ; 
its tissue felt soft and compressible. The fundus or upper division of the organ 
was fluctuant, and rounder in shape than it generally is after the discharge of 
the liquor amnii, which led me to conclude that a great portion of this fluid 
still remained. This opinion was corroborated when I attempted to ascertain 
the position of the infant through the abdominal parietes, for at the lower or 
cervical portion of the uterus, whence it was presumed the fluid had escaped, 
the projections of its body could only be felt. 

By a vaginal examination, I found the lower aperture of the pelvis very con- 
siderably diminished by the close approximation of the rami of the ischia and 
pubes which nearly destroyed the arch, and by their jutting forward there re- 
mained only a narrow slit, which would not admit the point of the finger. In 
the transverse diameter, two fingers could only just be placed between the tubera 
ischii ; the antero-posterior diameter was also much shortened by the coccyx and 
the lower part of the sacrum being considerably incurvated. This great dimi- 
nution in the outlet rendered it difficult to measure the brim, so that it was 
necessary to carry the hand very far backwards to accomplish it. Its figure was 
tripartite, or composed of three divisions. This alteration in the brim was 
occasioned by the falling downwards and forwards of the upper part of the sacrum, 
and the lower lumbar vertebrae which inclined a little more to the left side, and 
by the body of the ossa pubis and ischii being forced backwards and inwards, 
and by the jutting forwards of the symphysis and rami of the pubis. The 
measurement of the widest part of the conjugate diameter, in the two lateral 
divisions, did not exceed an inch and a half; I could only place two fingers, one 
lying a little over the other. The anterior diyision was not more than half an 
inch in its widest part, as it would scarcely admit one finger edgewise. The 
length of this narrow opening is not relatively available in practice. In the 
transverse diameter of the brim, I could just place three fingers parallel 
with each other. The external genitals were free from tumefaction, and the 
vaginal lining was moist, and of a natural temperature. Whilst lying on her 
side, I was unable to feel either the os uteri or the presenting part of the infant, 
but on placing her on her back (which occasioned her great pain), the os was felt 
to be dilated to rather more than the size of a shilling. She had not felt the 
movement of the infant since the morning, but by the stethoscope I satisfac- 



1850.] Midwifery, 231 

torily heard the pulsations of its heart, which fact Mr. Cluley afterwards corro- 
borated. 

Under these circumstances, the Caesarean section was considered as giving the 
best chance to the mother and child, and was accordingly performed. The incision 
was made to the left of the linea alba, it having been previously ascertained 
by auscultation that the placenta was not located there. 

Dr. Radford says that he has operated upon five women, of whom two have 
been saved and three lost. Of the three infants extracted, two were saved and 
three lost. 

One of the women who died had been in labour thirty-four hours ; the mem- 
branes were ruptured two hours afterwards ; pulse 150 in the minute, and 
feeble; repeated vomiting; had great tenderness in the belly, which was con- 
siderably increased by pressure ; great thirst; tongue furred and dry; great 
anguish expressed in countenance ; external genitals much swelled ; vagina hot, 
dry, and rough. On withdrawing the hand, an odour was perceived from it 
similar to that which takes place from partially decomposed animal matter. 
The movement of the infant had not been felt for some time, and its heart could 
not be heard by the aid of the stethoscope. When extracted, it was dead. In 
another of the cases which occurred, the woman had been in labour and the 
membranes had been ruptured twenty-two hours ; pulse 130 ; skin hot ; tongue 
furred ; thirsty ; pains very frequent ; had great tenderness in the belly, which 
was considerably increased by pressure. The infant was alive, but was de- 
stroyed by being spasmodically seized around the neck by the uterus. — Vide 
Edinburgh Medical and Surgical Journal, vol. Iv. p. 67. 

In the third case, the duration of labour was fifty-three hours, and the mem- 
branes had been ruptured fifty hours ; abdomen excessively tender ; fetid dis- 
charge from vagina ; pulse 130, irritable, and weak ; bowels had not been moved 
for several days; frequent vomiting; skin hot; great thirst. The incision being 
made, the intestines were exposed and much inflamed ; there was some serous 
efiusion of a red colour in the belly ; peritoneal coat of the uterus injected. 
The infant had not been felt by the woman to move, nor could the pulsation 
of the heart be perceived by the stethoscope. When drawn out, it was putrid. 

From the above statement of the condition before the operation, of the three 
women who died, we are warranted to conclude that their deaths were not 
attributable to the operation. We have in all of them indisputable evidence 
that the mischief was occasioned by protracting it, more especially in the two 
last-mentioned cases. 

Of the three infants extracted dead — in that of the first case we have every 
reason to believe it was so before the operation, as it was not felt by the mother, 
nor could we hear the pulsations of its heart. In that of the second case, it 
was alive, and its death is no doubt chargeable to the operation ; but it was 
produced by a cause which, I think, may in general be avoided, or at least 
guarded against. The third to be accounted for was already dead and putrid. 

49. C cesarean Operation successful hotli to Mother and Child. — An Italian 
journal, the Gazetta Medica Lombarda, reports the following case : A female, 
aged thirty-five, had for many years been subject to rheumatic pains in the pel- 
vic and lower extremities. Her first child was extracted dead. During her last 
pregnancy, she had a return of her arthralgia, during the persistence of which 
her body became so curved that she could not raise herself upright. Labour 
commenced on the morning of the 20th of June, and the midwife having re- 
cognized an arm presentation as well as a distorted pelvis, sought the aid of M. 
Custodi. By him it was soon ascertained that the transverse diameter of the 
brim was only two inches ; the oblique, three inches. Under these circum- 
stances, in accordance with the views of the Italian school, the Cgesarean opera- 
tion was at once decided upon, and performed six hours after the commence- 
ment of labour. The only bad symptom which followed was some degree of 
meteorism, which was combated successfully by the external and internal use 
of ice ; and on the ninth day the abdominal incision had perfectly closed. — 
Monthly Retrospect, Nov. 1849. 



232 Progress of the Medical Sciences. [Jan. 

50. On Local Bleeding in Displacement of the Uterus. — M. C. Ollivier, 
of Angers, observes that, during a fifteen years' practice, in which ute- 
rine diseases have especially occupied his attention, he has never met with 
a case of displacement of the uterus that was not preceded by a more or less 
considerable degree of engorgement; and that, instead of employing pessaries, 
and the whole variety of palliative bandages, he has been always enabled, by 
leeching the os uteri, to effect a radical cure. The careless way in which 
leeching this part has frequently been performed, has been the reason it has so 
fallen out of favour. In the first place, it should very rarely be undertaken, 
except in chronic uterine affections, when the congestion has become purely 
passive. Small leeches should be employed rather than large ones, the suction 
of the latter being too energetic, and their bites sometimes proving painful. 
They should never be employed in a large number, it being far preferable to 
renew their application frequently. In applying them, a small conical speculum 
should be used, so that the whole of the os uteri may not become inclosed within 
it ; for otherwise there is risk of the leeches entering within the cavity of the 
cerVix. It is from accidents, which have resulted from their doing so, that their 
application has been thought to be attended with danger. It is evident that 
considerable engorgements will yield only to repeated applications ; but these 
should be made by a small number of small leeches. — Brit, and For. Med.- 
Chirurg. Rev., Oct. 1849 ; from Gazette des Hopitaux, No. 103. 



CHOLERA. 

51. Fungoid Origin of Cholera. — The most interesting development which 
has been made in regard to cholera since the publication of our last Number, is 
the discovery, by Messrs. Brittan and Swayne, of a peculiar corpuscle in the 
vomit, dejections, and sweat of cholera patients, and in the atmosphere of infected 
localities. This corpuscle, supposed to be of a fungoid character, was hastily 
concluded to be the cause of cholera, and was believed by many persons to con- 
firm the hypothesis as to the fungoid origin of the disease. The able report of 
the cholera Committee of the London College of Physicians seems to us conclu- 
sively to overthrow this hypothesis, which, however ingeniously maintained, 
never had any substantial basis of facts upon which to rest. 

In the following articles, we have endeavoured to give a full summary of the 
principal observations which have been made on this subject, and also in regard 
to the nature and treatment of cholera generally. 

52. Discovery of a Peculiar Corpuscle in the Vomit, Dejections, and Sweat of Cho- 
lera Patients ; and in the Atmosphere of Infected Localities. — In the beginning of 
July last, Mr. Brittan, of Bristol, and Mr. Swayne, of Clifton, were deputed by a 
committee of the Bristol Medico-Chirurgical Society to examine microscopically 
the evacuations from two cholera patients, and to make reports and drawings of 
the appearances met with. The drawings were presented at next meeting of 
committee, and attracted attention from their representing bodies which each 
observer considered characteristic of the evacuations in cholera. In the " Me- 
dical Gazette" for September, 1849, Mr. Brittan has given the following account 
of his observations, which he has illustrated by drawings and a series of tables : 
" I examined, in conjunction with Mr. Swayne, two specimens of rice-water 
dejections, and, on comparing our drawings, we were struck with the peculiar 
appearance of certain bodies depicted in each. On further prosecuting this 
investigation, I found these bodies to be constantly present in the rice-water 
evacuations of the cholera patients, and offering the same characteristic appear- 
ance that distinguished them from anything I had before observed. In order to 
ascertain if they bore, in their size or quantity, any relation to the severity of 
the symptoms, I endeavoured to obtain specimens passed by the same patient 
at different periods, as well as to complete the observation by an account of his 
condition at the time. The result was, I became convinced that a certain rela- 
tion does exist between the size and number of these bodies, and the time 



1850.] Cholera, ' 233 

elapsed after the seizure, taken in connection with the severity of the symptoms. 
That is to say, they are small and clearly defined in the matter vomited ; they 
become larger and more compound in the dejections ; and, as the disease pro- 
gresses favourably, where I have had the opportunity of examining, they vanish 
as the symptoms disappear, and the motions regain their natural appearance. 
I have also found that in very rapidly fatal cases these bodies are sometimes to 
be met with only in very small quantity, or are altogether absent, though this 
observation must be qualified by the remark, that it is not always possible, or at 
all events has not been with me, to obtain portions of every motion passed, and 
that these bodies might have been present in those not examined. At every 
opportunity that I have had of examining the intestines of those who died from 
cholera, these bodies have been found adhering to the mucous membrane in 
shreds of Avhite matter, and very abundant ; and the inference is that, in these 
very rapid cases, they are in the intestines, though not given off in the evacua- 
tions. It must also be recollected, that but a small quantity is saved for in- 
vestigation, and but an infinitesimal part of that even ever comes actually on 
the stage of the microscope. My observations were made on cases taken just as 
they came under my notice, and without selection ; some in the cholera hospital, 
some through the kindness of Mr. Ralph Bernard, in the Bridewell: they 
extend in dates from July the 9th till July the 30th. Whilst collecting this 
series, I examined and compared the specimens with others obtained from 
patients free from cholera. I found that, in healthy solid motions, these bodies 
did not exist, nor could I meet with them in the fluid stools of typhus and other 
diseases ; but that they were present in the cases of severe choleraic diarrhoea so 
prevalent in districts where the disease abounds ; and I was thus led to the 
necessary inference, that these bodies were peculiar to the evacuations of cho- 
lera patients, and must have some essential relation to the disease. 

" Having been thus led to consider these bodies (which, from their charac- 
teristic appearance, I have termed annular bodies), in some manner essentially 
connected with cholera, I wished to ascertain whether it might be as cause and 
agent, or effect and product ; that it could not be the latter seemed evident at 
once from the fact that they were unlike any of the known healthy or morbid 
elements of the body, or secretions, and as they were found in the vomited 
matters apparently in an early stage of development, it seemed probable 
they were introduced from without, and would be met with in the atmosphere, 
&c., of places where cholera was rife. Accordingly, with the view to test the 
truth of this supposition, on July 19th, with the kind assistance of, and an 
apparatus suggested by, Dr. Bernard, I condensed about 3j of fluid from the 
atmosphere of a room in a house from which five patients had been removed the 
day previous to the cholera hospital, and found in it bodies of the same appear- 
ance as those in the stools. I soon afterwards repeated the experiment, with the 
aid of Mr. Ralph Bernard, in a cell in the Bridewell, which had been unoccupied 
for some time, but adjoining cells the occupants of some of which had been 
seized with cholera, one of whom died the day before. Here, also, the same re- 
sult was obtained. The same experiment was then tried in situations free from 
cholera, but with a negative result: the fluid here obtained was destitute of 
these bodies, and contained only small portions of hyaline structureless matter, 
also observed in the first. I have since repeated these experiments, aided by 
Dr. William Budd, several times with the same positive and negative results ; 
and therefore feel justified in stating that the same will follow similar investiga- 
tions made elsewhere, if the necessary care be taken, and a glass of sufficiently 
high power (I used a Ross's l-12th) be employed. The only question remaining 
is as to the identity of the annular bodies thus shown to exist in the atmosphere 
of cholera districts, and in the vomited matters and evacuations of cholera pa- 
tients. Most of those to whom I have shown the specimens entertain no doubt 
on the subject, and all seem to concur in their identity of form. This is all that 
is possible in respect to matters of such extreme minuteness, and we must, I 
imagine, be satisfied here, as in similar cases, to form our opinion on circum- 
stantial and corroborating evidence. And when we consider that this form is 
in itself of too definite a character to be one of mere chance ; that the sizes are 
progressive, accurate measurement showing those in atmosphere to average 



234 Progress of the Medical Sciences. [Jan. 

from the 10,000th to the 3,000th of an inch in diameter; those in vomit, from 
the 8,000th to the 5,000th ; those in dejections, from the 6,000th to the 500th; 
whilst they are met with in the same specimen of dejection in all the intermediate 
stages of palpably the same object; — the inference is, it appears to me con- 
clusive, that the annular bodies of atmosphere, vomit and dejection, are but the 
three stages of development of one and the same body, of whatever nature it 
may be. Those in the stools are found in almost all these stages, some being 
nearly as small as those in the atmosphere, others intermediate, evincing a 
commencement of compound character, whilst the largest again frequently seem 
parent cells containing young cells in their walls and interior, or broken up 
into a number of young cells more or less separated from each other. I have 
seen some much larger, occasionally entire, but more frequently broken with a 
sharp, irregular fracture, the morsels presenting, in some measure, the same 
characteristic annulus as the parent cell did. Their form is too peculiar to need 
further comment, the light ring round them giving a peculiar cupped appear- 
ance, which is unmistakeable, especially to one who has seen the drawings. 

" Having thus given a detailed account of the mode in which I was led to the 
discovery of these bodies in the atmosphere and evacuations, it might be ex- 
pected that I should enter more fully into a description of their nature ; but, as 
I have stated in the commencement of this report, my object is simply to lay 
before the profession the facts as I have found them, that they may receive the 
attention and examination which I believe they deserve, and be tested and 
proved by a repetition of my own experiments. To this end I shall be happy to 
give any information to those desirous of prosecuting the research, fully satis- 
fied that the more they are examined, the more fully will they be established, 
and the more important will be the results that may flow from their knowledge, 
and with the earnest hope that we may, through them, obtain, if no more, at 
least one common ascertained fact on which the profession may be agreed, and 
by which our inquiries into the cause and effect of this and other allied diseases 
may be directed in the right path. 

" On this account, also, I have studiously avoided giving any opinion at all on 
the facts brought forward, lest I might, by so doing, distract attention from 
them, and because I would wish them to stand alone as a fixed and demonstrated 
truth, from which others, as well as myself, may draw their inferences.'' 

After the above was placed in the printer's hands. Dr. B. was furnished by 
Mr. Quickett with the following, in a letter of date September 20th: "I have 
carefully examined the specimens procured by you from the air of cholera dis- 
tricts, choleraic vomit and evacuation, submitted for my opinion, on Friday, 
September 14th, as also a specimen obtained from the atmosphere this day ; and 
have no hesitation in stating that, in my judgment, they are successive stages 
of development of the same body, which I believe to be of a fungoid nature." 

In the same number of the " Gazette," Dr. Cowdell, of Dorset, announces 
that he and Mr. Corme of that place have found, in the clammy sweat accom- 
panying the last stage of collapse in cholera, " minute organized bodies, closely 
resembling other bodies admitted by naturalists and microscopists to have a 
protophytic organization." Dr. C. makes the simple announcement, and pro- 
mises details in a future number. 

Mr. Busk, surgeon to the Dreadnought hospital ship, made a communication 
to the Miscroscopical Society, on October 17th, on this subject: "With regard 
to the whole of the bodies seen in the air and water, and to a great proportion 
of the bodies found under the other circumstances, they were too indefinite and 
varied in their appearance and characters to be for one moment referred to the 
same species. The large bodies found in the matters passed from the system 
were most constant; and, after a careful examination of specimens from Drs. 
Brittan and Swayne, with their drawings, and with specimens procured by him- 
self, he believed they were of the following nature : 1st. A true fungus, very 
rarely seen ; being a species of Uredo, and identical with that found in bread 
affected with smut. This fungus is very common in bread ; and as it is not 
easily digested, its presence is readily accounted for. — 2d. Bodies of less size than 
the last, but under high magnifying power and defective illumination looking 
very much like them — and consisting of small particles of the inner membrane 



1850.] Cholera, 235 

of the grain of wheat. These bodies may be easily seen in the coarser kinds 
of bread; and drawings were exhibited giving their character before being 
taken into the body — which corresponded precisely with the specimens ob- 
tained from cholera patients. The presence of these bodies was also accounted 
for. — 3d. Bodies of lighter colour and more delicate. These were found to agree 
precisely with grains of starch from wheaten flour ; and drawings of both were 
exhibited. From these observations, Mr. Busk was led to conclude that the 
fungous theory derived little or no support from the facts brought forward by the 
miscroscopists of Bristol : although he did not deny that subsequent investiga- 
tion might lead to the discovery of something which had hitherto eluded ob- 
servation.^' 

Since the announcement of Mr. Brittan's discovery, a series of microscopical 
observations has been undertaken in Edinburgh by Dr. J. H. Bennett and Dr. 
Robertson, in order to test the accuracy of his conclusions. As these investiga- 
tions are still in progress, we cannot yet present our readers with the details : 
but we are authorized to state — 

1st. That the " annular bodies" des'cribed by Messrs. Brittan and Swayne 
have been frequently found in the '* rice water" evacuations of cholera patients. 

2d. That, in the majority of cases examined, they have not been seen. 

3d. That they have never been found in the moisture condensed from the 
atmosphere surrounding cholera patients in Edinburgh, nor in the water used 
in the city. 

4th. That they cannot be confounded with starch globules, as they resist the 
action of iodine. 

5th. That cholera evacuations often exhibit other and less equivocal vegetable 
bodies, such as sarcina, foruloe, and branched fungi. 

6th. That a magnifying poAver of 250 diameters is quite sufficient to exhibit 
the " annular bodies" when present. — Monthly Journal, Nov. 1849. 

53. Fungoid Origin of Cholera. — Dr. Nicholas Parker, Lecturer on Micro- 
scopical Pathology, at the London Hospital, in an interesting paper in the Lond. 
3Ied. Gaz., Oct. 1849, observes: — 

"The doctrine that certain epidemic and contagious diseases arise and be- 
come diffused through the agency of minute living organisms, is by no means 
a new theory. With various modifications, it has been more or less prevalent 
for centuries. But it had become well nigh exploded until attention was again 
directed to it in our own time by the able writings of Holland and of Henle. 
Various arguments have been adduced in its support ; the more important are 
of two kinds, negative and positive. 

The negative arguments are: — 

1st. The insufficiency of known phj^sical causes to account for the origin and 
spread of contagious diseases. 

Thus, to explain the causes of cholera, unwholesome food, and impure water, 
peculiarities of living, of climate, and of geographical situation, changes in the 
physical properties of the atmosphere, of its temperature, its hygrometric state, 
its electrical condition, and circumstances connected with the geological forma- 
tion of countries, have in turn been invoked and abandoned. The Hindoo, in 
the sultry plains of Bengal, who subsists chiefly on vegetable food, and the 
Russian, inhabiting a climate where the thermometer is many degrees below 
zero, and living almost exclusively on animal diet, have nearly equally suffered. 
Hill and plain, dry and moist situations, valle}'^ and mountain (as at Landour, 
8000 feet above the level of the sea) have all suffered, though in very unequal 
proportions. We cannot, in any of these circumstances, find a clear and suffi- 
cient explanation of the cause of the disease. 

2d. Chemical analysis cannot detect the presence of any deleterious agent in 
the atmosphere to which these diseases seem fairly referable ; and yet cholera, 
like typhus, influenza, and the exanthemata, is clearly dependent upon some 
wide-spread general cause. For it appears spontaneously in a district which 
had been previously healthy; it attacks simultaneously, or nearl}^ so, a number 
of persons; it is migratory in its course, passing from one locality to another, 



236 Progress of the Medical Sciences. [Jan. 

and that frequently at a considerable distance ; it attacks individuals of both 
sexes, of every age, and of every constitution. 

Epidemic diseases, then, cannot be referred either to changes in the knov^^n 
physical properties of the earth, air, M^ater, or food, or to chemical altera- 
tions of the ingesta and circumfusa (for the ozone theory seems to be quite dis- 
proved by the remarks in the " Medical Gazette" of last week) ; and hence they 
have been thought by some to be dependent upon a minute living organism, an 
animated principle of contagion. The follow^ing are some of the more import- 
ant positive arguments by means of which this view has been attempted to be 
supported : — 

1st. The increase of these diseases is promoted, retarded, or arrested by 
means that promote, retard, or arrest the growth and development of such 
minute living organisms. Along the courses of rivers, more particularly where 
they form a delta, rarely at their source, in alluvial basins and in damp situa- 
tions generally, wherever large masses of animal matter, in a state of decom- 
position, are allowed to accumulate — as about sewers, and those plague spots, 
the metropolitan graveyards — there do we find cholera, typhus, and their con- 
geners, to be rife, and there do they commit the greatest ravages: and these are 
precisely the circumstances which favour the increase and development of the 
lower organized forms. 

2d. The poison which produces many of these diseases possesses a capability 
of increase when received into the body, reproducing itself at the expense of 
foreign organic matter, so that the effect produced is not at all in relation to 
the frequently small quantity of poison taken into the system. Like yeast, 
which is known to be a minute fungus, torula cerevisioe, these poisons increase 
by assimilation. Just as a small quantity of yeast will suffice for the fermenta- 
tion of a large amount of saccharine solution, and, growing, will increase a 
thousand-fold, so a single drop of small-pox virus will, when received into a 
living body, reproduce many drachms of a fluid endowed with like contagious 
properties. But no inorganic substance possesses such a faculty, and hence the 
reproductive power must be ascribed to a living organism, and most probably 
to a minute vegetable germ, or cell. This view is still further strengthened by 
the fact of the poison remaining latent in the system for a certain period. 

3d. Minute vegetable parasites, or their germs, have been actually observed 
in connection with abnormal states of living plants, of animals, and of man: 
By linger [Beitrdge zur vergleichenden Pathologie, 1840, p. 1), in the parenchyma 
of the leaf of chrysomyxa abietes. By many observers, in different species of 
grain. By Meyen ( Weigmann's Archiv, 1840, bd. ii. p. 64), on the body of 
vibriones. By Westwood ( Westwood's Ann. of Nat. Hist., 1841, Nov.), on the 
surface of the silkworm of China. By Busk [Microscopical Journal, 1840, vol. 
i. p. 149), on the surface of dytiscus marginalis. By Bassi [Del Mai del Segno 
V. Moscardino, 1837), and Audouin [Ann. des Sciences Nat., t. viii. pp. 229- 
257), on the surface and in the interior of the common silkworm. Bj Lau- 
rent [L'Institut, t. vii. 1839, No. 288), in the albumen and vitelline membrane 
of the ova of limax agrestis." By Ehrenberg [Froriep's Neue Not., 1839, No. 
18), in the salmo eperlanus. By Mliller {Archiv, 1841, p. 477), Ketzius {Ibid. 
1842, p. 193), and Creplin [Weigmann's Archiv, 1842, bd. xiv. p. 61), in pike 
and other fish ; and by Goodsir and Bennett ( Transactions of the Royal Society 
of Edinburgh, vol. xv. part 2, 1842), in the cyprinus auratus. By Henle [Pat. 
Untersuch, p. 4), and by Hannover [Mailer' s Archiv., 1839, p. 338 ; and 1842, p. 
77), on the toes and integument of triton cristatus and punctatus. By Stilling 
[Ibid., 1841, p. 379), on the surface of frogs. By Rousseau and Serrurier ( Compter 
Rendus, 1841, 5 Juillet), on the surface of testudo Indica, and in the abdomen 
of hens, doves, and many other birds. By Bayer [L' Institut, 1842, No. 450), 
and by Pappenheim [Geioebelehre des Anges, p. 217), in the yolk of hens' eggs. 
By Mliller and Betzius [Midler's Archiv, 1842, p. 198), in the respiratory tract 
of stryx nyctea, and of falco rufus ; and by Reinhardt [Ibid., p. 294), on the 
surface of the lung of various birds. By Ecker ( Verhand der Natur Gesellschaft 
in Barol, bd. vii. p. 95), in a closed capsule contained within the abdomen of a 
raven. By Bennett [op>. cit.), on the face of a mouse. By Langenbeck [Fro- 
riep's Neue Not., 1841, No. 422), in the nasal discharge of a horse with glan- 



1850.] Chohra. 237 

ders; and by Remak [Diagnos. und patliog. TJntersuch, p. 225), in the contents 
of the stomach and intestines of rabbits, oxen, sheep, and pigs. 

In man, cryptogamic plants have been found growing on the skin and mucous 
membranes, both during life as well as after death, and they have also been 
detected in many of the secretions and excretions of the economy. 

On the skin they have been observed by Remak [Med. Vereinszeit, 1840, 
No. 16), Gruby [Comptes Reiidus, 1841, 12 Juillet and 2 Aoiit), Bennett [op. 
cit.), and others, in favus ; by Gruby [Comptes Rendus, 1842, Sept. 5), in men- 
tagra and porrigo decalvans (Herpes tonsurans of Cazenave) ; by Gunsburg 
{Pat. Geioebelehre, bd. ii. p. 30), in trichoma; and by Sluyter [De Veget. par 
Ber. 1847), and Simon (^Hantkrankheiteii, p. 311, 1848}, in pityriasis versicolor. 
On the mucous membrane of the mouth their presence has been signalized in 
a form of aphthge (muguet of the French), by Vogel [Allgem. Zeit.fitr Chi- 
rurg., 1841, No. 24), Gruby [ArcJiiv. Gen., 1842, Juin), and others; and by 
Hannover [MilUer's ArcJiiv, 1842, p. 285), and Bennett [op>. cit.), in the coat- 
ing of the tongue. On the fauces and oesophagus by Hannover [op. cit.). On 
ulcerated spots in the intestines by Langenbeck [Froriept's Neue Notizen, 1839, 
No. 252). In the posterior chamber of the eye by Ilelmbrecht [Casper's 
Woclienschrift, 1842, p. 593). In tubercular cavities, and in sputa, by Bennett 
[op. cit.) and Rayer [U Institut, 1842, No. 448). In the fibrinous coats of the 
small bronchial tubes which are expectorated in pneumonia, by Remak [op. 
cit., p. 222). In vomited matter, by Goodsir [Edin. Med. and Surg. Journ., 
1842, April), as well as by Grub}^ Vogel, and Busk. In all fluid dejections, 
no matter how produced, whether by typh-us, dysenter}^ errors in diet, or pur- 
gatives, by Remak [op. cit., p. 226), and in the evacuations of cholera patients, 
by Boehm [Die Kranke Darmsclileimliant in der Asiatisclien Cholera, 1838, p. 
57). In carious teeth, by Erdl. In milk, urine, mucus, and pus, by many ob- 
servers. We have now to add to the list, their presence in cholera evacuations, 
where they have been recently again pointed out by Messrs. Brittan and 
Swayne [Med. Gaz., No. 1139), and in the perspirations of cholera patients, 
by Dr. Cowdell and Mr. Curme [ibid.). 

That such vegetable parasites are not unfrequently met with in diseased 
conditions of animals and man, appears to be unquestionable, and we have now 
to inquire : — 

1st. Whether they or their germs exist in the fixed vehicles of contagions, 
and in contagious atmosphere. 

2d. Whether they are invariably present in contagious diseases, and in those 
diseases only. 

3d. Whether a causal relation obtains between them and the diseased state. 
The exanthemata frequently arise spontaneously, and still more frequently 
perhaps they are communicated by contact with the sick, or the air surround- 
ing them. They are produced as well by a something mixed with the air, as 
by a something existing in, and emanating from, the bodies of the sick. The 
something mixed with the air, and the something emanating from the sick, may 
fairly be presumed to be identical. In the exanthemata, the something which 
possesses the faculty of exciting the same disease in a person previously healthy, 
is known to be associated with certain fluids of the body — viz. blood, lymph, 
and pus, for the disease may be communicated by inoculation with those fluids. 
But the most careful microscopical examinations cannot detect anything differ- 
ing from normal blood and pus in the blood which, placed beneath the cuticle, 
causes measles, or the lymph which causes small-pox. Moreover, the constitu- 
ents of blood and pus cannot traverse the atmosphere, and those substances 
must therefore act merely as vehicles of contagion. As for the principle of 
contagion itself, it completely escapes all our moans of research, and its mate- 
rial existence cannot be proved at all : still less can it be proved to be a fungus. 
In the muscardine, a disease which prevails epidemically among silkworms, 
and which is undoubtedly caused by a fungus, it results, from the researches 
of Audouin, that the fungus is invariably present, and in every stage of the 
disease ; that it is always one and the same fungus ; and that the disease may 
be communicated to healthy worms by inoculation. This is also the case in 
favus. Is it so in cholera? are Mr. Brittan's annular bodies alwavs present? 
No. XXXVIL— January, 1850. 16 



238 Progress of the Medical Sciences. [Jan. 

Mr. Brlttan himself states that, " in very rapidly fatal cases, these bodies are 
sometimes to be mst with only in very small quantity, or are altogether absent/' 
In the evacuation of a patient admitted to the London Hospital with cholera, 
which proved fatal in twelve hours, I could not discover these bodies. It does 
not appear, then, that this fungus is invariably present in cholera evacuations, 
and it seems particularly suspicious that it should be absent precisely where 
we should expect to find it in greatest abundance — that is, in the most rapidly 
fatal cases. I leave for future investigation the solution of the point whether 
the bodies found in the air, vomit, and dejections are of one and the same 
nature. Nor do I purpose entering into any discussion as to the precise nature 
of the bodies themselves, a question which requires a more extended investiga- 
tion. 

Granting them to be, as stated, of a fungoid nature, different species of fungi 
have been found by Kemak, in nearly all forms of fluid dejections, no matter 
how brought about, and the presence of a fungus, differing, it is true, from that 
described by Messrs. Brittan and Swayne, in the stools of cholera patients, has 
been especially noted by Boehm in his work on the morbid states of the intes- 
tinal mucous membrane in Asiatic cholera. 

3d. Does a causal relation obtain between these fungi and the diseased state? 
The foregoing considerations lead me to answer this question in the negative. 
For — 1st. The active principle of the fixed vehicles of contagion cannot be 
proved to be a fungus, and therefore analogy would lead me to predicate the 
same respecting that of contagious atmosphere. 

2d. Even were fungi present, they must be proved to be essential, and not 
accidental — the cause of the disease, not its symptom ; for fungi are present in 
various and most different states of the economy, often without giving rise to 
any particular symptoms. 

3d. But these bodies do not seem to be invariably present in the evacuations 
in cholera : they cannot, therefore, be its cause. 

4th. The presence of a few fungi does not serve in any way to explain the 
terrible symptoms of cholera. Nor is our knowledge of the essential nature 
of this mysterious affection thereby materially advanced. 

54. Cholera Sporules. — The following observations, communicated to the Loud. 
Med. Gaz. (Oct. 1849), by Mr. W. R. Bash am, tend to show that the cholera 
sporules cannot be the cause of cholera, as they are not apparent in the cholera 
discharges until a certain period after the evacuation of these fluids from the 
body, when they are developed by the spontaneous change which the fluids 
undergo. 

"Desirous," he says, "of examining the cholera sporules from some cholera 
fluid, I obtained the serous discharges of a male patient, set. 12, who was col- 
lapsed, pulseless, cold, and livid. In less than half an hour, this fluid was under 
microscopic examination, and the appearances were similar to what I had 
observed in previous examinations of this fluid — abundance of broken-down epi- 
thelium, mucous globules, and disintegrated fibrine, and a few bead4ike aggre- 
gations of minute crystals of oxalate of lime. The appearance of these crys- 
tals in the serous discharges of cholera has been observed also by Dr. Waldo 
Burnett [Americaii Journal of Medical Sciences, July, 1849). I could detect 
no cholera sporules, after a very patient examination of more than an hour. 
Four hours after, the appearances in the field of the glass were similar ; one or 
two cholera sporules were now visible, and, as successive drops of fluid were 
submitted for examination, they became more numerous. Fourteen hours after, 
similar appearances to those first observed, with the addition of numerous pris- 
matic crystals of the triple phosphate, and the cholera sporules, had become 
very numerous ; they were more abundant in the shreddy membranous por- 
tions to which they seemed attached. 

Tuesday, Oct. 2d, fourth day. — Fluid in a state of most offensive decomposition ; 
all trace of sporules had disappeared ; much shreddy membranous debris, like 
broken-up and decaying fibrine; millions of vibriones in active motion ; nothing 
else, after a very patient examination of many successive portions of the fluid, 
could be detected than these animalcules, and the decomposing membranous 



1850.] ' Cholera. 239 

structures. On Monday, Oct. 1st, I again examined the serous fluid from an- 
other cholera patient, and within the first three hours I could not detect any 
sporules in successive portions of the fluid : in about four hours, they first became 
visible ; in ten hours, they vs^ere abundant, with many crystals of the triple 
phosphate ; and on the third day they were displaced by the ordinary vibriones 
of decomposing animal fluids. 

55. Report on iJie Nature and Import of Certain Microscopic Bodies found in 
the Intestinal Discharges of Cholera. Presented to the Cholera Committee of 
the Royal College of Physicians, by their Sub-Committee, on Oct. 17th, 1849. 

We propose, in this Report, to lay before the Committee the results of some 
experimental inquiries on a subject which, within the last few weeks, has en- 
gaged much of the attention of the profession. We allude to the discovery, b}' 
Mr. Brittan and Mr. Swayne, of Bristol, of peculiar bodies in the " rice-water" 
dejections of cholera patients ; and to the statement that similar bodies have 
been found by Mr. Brittan in the atmosphere, and, subsequently, by Dr. W. 
Budd, in the drinking-water of infected localities. 

These observations, on account of their important bearing, if true, on the 
pathology of cholera, seemed to us to demand a searching examination. We 
have, accordingly, given much time and attention to the subject. Having, in 
the first place, satisfied ourselves of the distinctive characters of the bodies 
found in the rice-water dejections, we next sought to verify the observations of 
Mr. Brittan and Dr. Budd with reference to their presence in the air and drink- 
ing-water of places infected with cholera. It was necessary that this part of 
the inquiry should not be delayed, for the epidemic had already reached its 
turning point, and it would, before long, have been difficult to obtain favourable 
opportunities for experiments of a satisfactory character. 

Our inquiries were afterwards directed to the nature and properties of the 
newly-discovered corpuscles, and to the question of their occurrence in other 
diseases. In this investigation, we soon perceived that objects totally difi'erent 
had been regarded as identical ; but we had arrived at no positive conclusion 
respecting those which seemed most characteristic of the cholera evacuations, 
when we received two important communications on the subject from Mr. 
Marshall and Dr. Jenner. The letters of these gentlemen are appended to this 
report ; but the results obtained by them are embodied in it. 

Our observations on the air and drinking-water of infected localities, twenty- 
four in number, gave uniformly negative results. With regard to the value of 
our experiments, taken separately, it will, we think, appear that many are 
liable to no objection. Some of those which relate to the drinking-water of in- 
fected places are certainly wanting in the conditions which would make them 
convincing. But, when it is considered that Dr. Budd believes he has detected 
the objects sought for " in great numbers, ^^ in such large bodies of water as the 
Float, at Bristol, and the Surrey Canal, and that he represents them as being 
deposited in the sediment of the water, we shall not be thought unreasonable in 
having expected that they might be discovered in the cisterns of houses and 
public institutions in which cholera had prevailed severely, although it had 
ceased there for some days or weeks. 

Nevertheless, a much larger amount of evidence would have been required to 
disprove the statements to which our observations refer, had those statements 
been unassailable from other points. But the facts to be detailed in the sub- 
sequent part of this report will show that the bodies found in the rice-water 
dejections have no peculiar relation to cholera ; and that, if they should occa- 
sionally be present in the atmosphere, or impure water, this will not happen 
exclusively, or even especially, in districts infected with the epidemic. 

We shall now submit the particulars of all the observations to the Committee, 
describing, first, those on the air. 

Microscopic Observations on Water condensed from the Atmosphere of Infected 
Localities. — Two methods were employed for condensing the aqueous vapour. 
One was to suspend in the air to be examined a glass funnel, nearly filled with 
a freezing mixture, its lower opening having previously been closed by a cork, 
and covered with sealin^r-wax. The moisture, condensed on the outside of the 



240 Progress of the Medical Sciences. [Jan. 

funnel, trickled into a small phial placed beneath. The second method was to 
force air slowly, by means of bellows, through a bent glass tube immersed in 
ice and salt — when the moisture was deposited on the interior of the tube, and 
collected in a bulb at its lower part. In either way, from half a drachm to a 
drachm of water was readily obtained. 

Ohs. 1. — In Millbank prison, from the 6th June to the 16th September, there 
occurred eighty-four cases of cholera. The last patient began to suffer from 
diarrhoea on the 16th September, and died on the 25th. On the 19th, when he 
lay in a state of collapse, about a drachm of water was condensed from the air 
of a lobby which separated his small apartment from a water-closet, in which 
his evacuations were emptied. The water thus obtained was submitted to 
microscopic examination the same evening. 

Ohs. 2 and 3. — On the same day (the 19th of September), we accompanied 
Mr. Bayfield, one of the surgeons of the Union of St. Olave's, Southwark, to 
two localities in his district, in which cholera had been most prevalent, namely, 
English Ground, Bull Court, Tooley-street, and Gimber's Rents, Snow's Fields. 
In a ground-fioor room of a house in the former court, a woman and child had 
died of cholera within a few days ; and the husband, at the time of our visit, 
was in bed, ill with the disease. Nearly a drachm of water was obtained from 
the noisome atmosphere of this room. 

In Gimber's Rents, the drainage and the ventilation were as bad as possible. 
In several places, we saw the openings of drains covered with matting, to pre- 
vent the escape of effluvia. We collected about a drachm of water from a house 
where a woman lay ill of cholera; her husband having only recently died of 
the epidemic. The water procured in these two experiments was examined 
the same evening, and the examination of it repeated on several subsequent 
days. 

From Gimber's Rents we brought away a piece of bread which had been long 
in the house, and which had not been cut for a week ; a piece of butter, the 
surface of which was covered with dust, and a jug, which we found filled with 
drinking water. The examination of this water will be referred to in our 
second series of experiments. On the bread and the butter, no bodies like 
those observed in the rice-water evacuations could be found. 

Ohs. 4 and 5. — On the 22d September, water was condensed from the atmo- 
sphere in two houses situated in St. Erman's Hill, near the Broadway, West- 
minster. Mr. Painter, surgeon of St. Margaret's parish, to whom we had ex- 
plained our object, conducted us to this localit}^, as, at that time, the chief focus 
of the disease. In one house (No. 21), a child lay dead, having been attacked 
with cholera the preceding evening. Two other cases had recently occurred 
in the same house. At No. 12, a child was ill of cholera ; and a second had 
been removed, in the morning of the same day, to the Cholera Hospital, where 
it died. Mr. Brittan and Mr. Newport took part in the microscopic examina- 
tion of the water condensed from the air in these houses, about an hour after 
it was collected; but, like ourselves, were unable to discover any "annular'^ 
bodies. On the following day, the same water, as well as that procured in the 
second and third observations, was again examined by Mr. Brittan, and with 
the same result. 

Ohs. 6. — On the 6th October, cholera appeared amongst the patients in the 
insane ward of the Birmingham Workhouse ; many were attacked. On the 9th 
of October, at our request. Dr. Fletcher, of Birmingham, kindly obtained for 
us some water condensed from the atmosphere of this ward, and likewise from 
that of one above it, when diarrhoea was prevalent. These specimens of water 
reached us, and were examined by us on the 11th October. 

Ohs. 7. — From the beginning of the month of October, cases of cholera had 
been numerous and fatal in the workhouse of the Walsall Union; partly im- 
ported, but partly occurring in inmates of the workhouse. When the epidemic 
was at its height, we obtained, through the kindness of Dr. F. Burton, of Wal- 
sall, about a drachm of water from the air of the room in which the greater 
number of the cases occurred. This specimen of water was condensed from 
the air on the 7th, and was examined by us on the 8th October. 

The water condensed from the air in the several localities, and under the 



1850.] Cholera. 241 

circumstances we have described, was, in each case, examined by us more than 
once. But the search for " annular" bodies, such as those found in the cholera 
dejections, failed, as we have already intimated. Neither cells, nor rings, nor 
anything bearing any resemblance to them could, in most cases, be discovered. 
"We saw merely portions of gelatiniform matter containing bright points — some- 
times finely granular, brownish masses, perhaps derived from smoke — and occa- 
sionally colourless, transparent particles, of a crystalline appearance, which 
may have been portions of siliceous dust. After the water had been kept some 
time, chains of delicate oval vesicles, like those of the torula of yeast, but much 
smaller, appeared in it. These were absent at first, and could not be mistaken 
for the cholera discs. Equally unlike those discs were the three or four separate 
oval cells, which, in two instances, were seen in the water when first examined. 
They had a clear, single outline, and were not flattened. 

Microscopic Observations on the Brinking-ivater of Injected Places. — Obs. 8. — 
On the 26th September, Dr. Snow kindly furnished us with a specimen of 
water from Albion-terrace, Wandsworth, a locality in which cholera had been 
very fatal between the 28th July and the 13th August. This water, which was 
very foul, had been taken from a tank at Albion-terrace on the 16th or 17th of 
August ; but, as it had been kept so long before it was submitted to microscopic 
examination, it may be objected that, had "cholera fungi" originally been 
present, they might have become decomposed or otherwise destroyed. 

Obs. 9. — A second specimen of water, sent to us at the same time by Dr. 
Snow, was obtained from a house in Gresse-street, Rathbone-place, in which 
five persons had recently died of cholera. The last case of the disease here 
occurred two days before the water was obtained from the cistern, and twenty- 
four days before it was examined by us with the microscope. 

Obs. 10. — From the 31st August to the 7th September, four fatal cases of 
cholera occurred amongst the female prisoners in two wards of the Millbank 
Prison. The part of the building where these wards were situated was forth- 
with vacated. On the 19th September, a portion of water with sediment was 
taken from the cistern which supplied those wards, the contents of this cistern 
having remained undisturbed since the removal of the prisoners to another 
part of the building. At the same time, specimens of water were taken from 
the cistern of the female infirmary, where two fatal cases of cholera had oc- 
curred simultaneously with those above referred to, and also from the tank 
which supplies the whole prison. These three specimens of water were sub- 
mitted to the microscope the next day. 

Obs. 11. — The drinking-water taken on the 19th September from the house 
in G-imber^s Rents, Borough (see 055.3), deposited a sediment which was care- 
fully examined. The description of the locality has been already given. 

Obs. 12. — On the 27th September, we visited Crosby-court, Bermondsey, an 
open space containing seven houses. Four cases of cholera (two fatal), had 
recently occurred in one of these houses, the others having escaped. The 
house in which cholera had been fatal was closed. But we found that the 
water used by the inhabitants of the court came from two pumps ; one supplied 
from the Thames water, the other raising well-water, which was hard and ferru- 
ginous. On a strict inquiry, it appeared that the Thames water was used for 
drinking in every house except the one in which cholera had appeared ; in that 
house, only the well-water was used. We brought away water from both 
pumps, and examined the deposits, which were abundant, on the following 
day. 

Obs. 13. — We next went to Jacob's Island, Bermondsey, a most crowded and 
wretched part of the district, in which cholera had been very severe. It is a 
portion of low ground bordering the river, and surrounded by a shallow tidal 
ditch, which receives the contents of the privies on either bank. The water for 
drinking and other purposes is taken, for the most part, from this ditch. We 
procured some water from the ditch itself, and also from two pumps supplied 
from it, situated in Gutteridge's-court, where deaths had occurred. 

065. 14. — On the same day we also went to Ilanover-street, Rotherhithe, a 
low and crowded cul-de-sac. A woman lay dead of cholera in one of the houses ; 
and other deaths had occurred. The water used, of which we procured a spe- 



242 Progress of the Medical Sciences. [Jan. 

cimen, was derived from the Thames, through a pump which became dry at 
every ebb. Behind the houses, on the east side, was an open ditch, receiving 
the refuse from them and conveying it into the Thames, at a point close to the 
opening of the pipe which supplied the pump in the street. 

Obs. 15. — In a house in Swan-lane, Rotherhithe, close to the Millpond, a man 
lay dead of cholera. The disease had been fatal in two adjacent houses. The 
woman, whose husband had just died, told us that she and most of the inhabit- 
ants took their water for drinking from the Millpond, which is a tidal ditch, 
serving as a sewer to the houses on its banks. We filled a bottle with water 
from this source. 

Obs. 16. — Dr. Burton, of Walsall, forwarded to us, on the 7th October, three 
specimens of water from the workhouse, cholera prevailing at the time amongst 
the inmates. (See Obs. 7.) The first was from an open cistern fed by land 
drains, the second from a moat, the third from cisterns in the workhouse. The 
last water, which is that chiefly drunk by the paupers in the workhouse, is 
derived from the moat, but is filtered through charcoal and gravel. The depo- 
sits of all were carefully and repeatedly examined. 

Obs. 17. — To Dr. Fletcher, of Birmingham, we are indebted for five specimens 
of the water which supplies the workhouse, forwarded to us at the time cholera 
prevailed in the insane ward of the establishment. (See 055.6.) The specimens 
included: 1. Clear water from the reservoir which is supplied from the river. 
2. Sediment from the reservoir. 3. Clear water from the cistern of the work- 
house. 4. Sediment from the bottom of the cistern. 5. Sediment from the 
side of the cistern. These specimens were examined on the 11th inst., and the 
examination of them has been most carefully repeated. 

Obs. 18, 19, 20, 21, and 22 were all made on water obtained for us by Mr. 
Hunt, one of the assistant-surgeons at the Westminster Cholera Hospital, from 
several parts of the district called Palmer^s Village, which we have ourselves 
inspected. The names of the places are Goodman's Green, where the water 
used for all purposes is contained in a filthy open trough ; Perrin's-place ; a 
house (No. 3) in Perrin's-court, in which five cases of cholera (two fatal) had 
occurred; a house (No. 2) in Providence-row, where also there had been five 
oases (three fatal) ; and the Dispensary, Palmer's Village, at which two sur- 
geons successively had been attacked with cholera, one fatally. Cholera had 
prevailed in all these localities, but not within a fortnight of the time when the 
water was taken for examination. 

Obs. 23. — In a small house (No. 9) in Dorset-place, Vauxhall-road, three 
cases of cholera had occurred in succession ; the first on the 5th instant, the 
second (fatal) on the 8th, and the third (also fatal) on the 12th. These cases 
were attended by Mr. Clark, of St. James's-terrace. On the 8th instant, just 
after the second case occurred, two specimens of water were, at our request, 
taken from the butt supplying the house — one from the surface of the water, 
the other from the tap after the sediment had been stirred up ; and both have 
been several times examined with the aid of the microscope. 

Obs. 24. — On the 5th October, a man labouring under cholera was admitted 
into University College Hospital. He had resided for some months at No. 4, 
Howland-street. A week previous to his attack, he had changed his room to 
another in the same house, where a woman had died of cholera seven weeks 
before. Water was taken from the kettle, and from a stone water-jug in his 
room, as well as from a cistern which supplied the house. As he had dined in 
another house on the day previous to his attack, water was procured thence 
also. The deposits of these several specimens were likewise submitted to care- 
ful microscopic examination. 

The uniform result of these experiments, as of the former series, was negative. 
No bodies were found which could be regarded as identical with the more cha- 
racteristic of those discovered by Messrs. Brittan and Swayne in the rice-water 
dejections of cholera. The objects met with were far more numerous than those 
seen in the moisture condensed from atmosphere. The sediment, when viewed 
with the one-eighth-inch object-glass of Ross, or one-sixteenth-inch object-glass 
of Powell and Lealand, presented, besides amorphous matter, an almost endless 
variety of organic forms, both animal and vegetable. Amongst these were 



1850.] OMera. 243 

many round or oval cells, of various dimensions, and some separate rings of 
minute size, colourless, and pellucid. The cells had generally very delicate 
walls and a clear cavity, were never flattened, and often contained a multitude 
of distinct granules, which, in some instances, presented the molecular motion. 
Like the rings, these cells were obviously different in their nature from the 
thick-edged discs which the descriptions and drawings of Messrs. Brittan and 
Swayne and Dr. Budd had led us to regard as the characteristic corpuscles of 
the cholera evacuations. 

The negative results of our search in the atmosphere of infected places, for 
objects identical with those just referred to, are confirmed by some observations 
communicated to us by Mr. Marshall. While cholera was prevalent in St. 
Giles's, he examined the dirt washed from the broken glass of windows, and 
from cobwebs taken from houses in that district, in which deaths had occurred 
from four to ten days previously. With one-twelfth-inch or one-eighth-inch 
object-glass, he found a vast number of objects, such as particles of silex and 
soot, hairs, wings, and legs of insects, round and oblong cells of a brownish 
colour, very dark spherical granular masses, probably of a confervoid nature, 
and fragments of vegetable tissue, amongst which were pieces of spiral tubes, 
and entire rings, apparently of woody tissue, of an oval, polygonal, or circular 
form. But he detected no discs with double outline. A microscopic examina- 
tion of the objects collected on a moist surface from the atmosphere of sewers, 
gave Mr. Marshall a similar negative result with regard to those discoid bodies ; 
although he found (besides fine particles of silex and other dust) brown, oval, 
and round cells, single and in couplets, minute colourless vesicles, either single, 
double, or in triplets, a single large oval cell, and numerous opaque, granular, 
confervoid bodies, of a brownish or blackish-green colour. 

Microscopic Observations on the Bodies found in the Cholera Dejections. — We 
next proceed to show how various are the bodies which have been confounded 
together under the terms annular bodies (Mr. Brittan), cholera cells (Mr. 
Swayne), and cholera fungi (Dr. Budd). 

On examining the drawings given by the three gentlemen who have called 
attention to the subject, four principal forms, which can hardly belong to the 
same objects, may readily be distinguished. 

1. Rings, which enclose a free area, and which often are broken. These are 
usually of minute size, according to Mr. Brittan and Mr. Swayne, but occa- 
sionally large, according to Dr. Budd. 

2. Globular, or oval cells, chiefly of the middle size, which have a thick wall, 
with numerous small eminences on its surface, and contain a granular mass, 
in some instances, separated by a clear space from the wall of the cells. These 
are distinctly figured only by Mr. Swayne, but are regarded by him as per- 
fectly developed cholera cells. 

3. Bodies having apparently the form of discs, ivith thick rounded edges, and 
centres of indistinct structure. These vary extremely in size, including some 
of nearly the smallest, as well as many of the largest, of the objects repre- 
sented by the three observers. They predominate in all the representations 
given of the corpuscles of the rice-water dejections, and must be taken as the 
type of the bodies discovered by Messrs. Brittan and Swayne. 

4. Large broken cells, having apparently homogeneous membranous walls, 
and containing small, well-defined, oval bodies ; figured by Dr. Budd as cholera 
fungi undergoing decay, but differing in character from all the other objects 
represented. 

A mere inspection of these different figures would suggest strong doubts as to 
their representing different appearances of really identical bodies in different 
states or stages of development or decay. The more particular description we 
have now to give of each kind of body will demonstrate that they are of various 
and distinct nature. 

1. The rings, when closely examined, are seen to be of different kinds ; some 
perfectly continuous in their entire circle ; others formed by a curled fibre ; 
some round, some oval, others lozenge-shaped. 

vSome of these have been traced to their true source by Mr, Marshall, who 
has found that exactly similar objects may be prepared by the artificial digestion 



244 Progress of the Medical Sciences. [Jan. 

of the vegetables used as food — such, as cabbages, potatoes, and onions, the 
withered style of wheat grain, and portions of cane in sugar; the spiral and 
annular tissues of which break down into rings of different sizes, or coils re- 
sembling rings. 

Intermediate between these and the third class of bodies are minute, oval or 
round, colourless corpuscles, which have an annular appearance; but, on close 
inspection, are seen to have their area filled up with a transparent substance, 
presenting sometimes perforations. In some specimens of the rice-water fluid, 
oval bodies, in part having their middle filled up as here described, and, in part, 
mere rings, exist in extraordinary abundance. The rings of these bodies have 
been observed, by Mr. Busk and Dr. Grifiith, to be divided by cross lines, into 
segments, which Mr. Busk thinks are bead-shaped — an appearance which had 
occasionally been noticed by ourselves as well as by Mr. Marshall. They are 
calcareous structures, originally derived from chalk, in which they abound; and 
they have been introduced into the contents of the intestines with the medicines 
(chalk-mixture, aromatic confection, &c.) which the patients have taken."^ 
These minute bodies from the chalk are, of course, not found in all cases ; and 
we think it not unlikely that, in their absence, the separated nuclei of animal 
and vegetable structures, as well as the vegetable rings above described, may 
sometimes have been mistaken for fungi. 

2. The globular bodies have been clearly identified by Mr. Marshall with the 
spores of diiferent kinds of uredo, the rust, smut, and bunt of grain ; some 
species of which may be found, not only about the withered style on grains of 
wheat, but also in almost every specimen of corn and bread. 

Mr. Busk has made the same observation, and identifies them with the uredo 
segetum, or bunt. 

3. Discs, with thick, elevated, and somewhat irregularly-curved margins; the 
central area flattened, and obscurely granular. They have generally a yellowish, 
or pale brown tint, which varies in depth with the colour of the fluid containing 
them. These are the most peculiar of the bodies found in cholera, and difier 
from the rest in being more or less soluble in ether. Mr. Marshall, who first 
informed us of this fact, found that the smaller discs undergo nearly complete 
solution, leaving a cavity in the dried mucus, whilst the larger ones leave a fine 
granular film. They are apt to break across, and the thick margin to curl in- 
wards. They are evidently not cells, nor have they any organized structure 
which could give them any claim to be regarded as living organisms. On the 
other hand, their solubility in ether shows that they consist, in great part, of 
some substance of the class to which the fats, resins, and saponaceous matters 
belong. This observation led Mr. Marshall to examine different fatty substances, 
and at length to find that curled concretions, not unlike the discs found in 
cholera, could be obtained by compressing a piece of rich cheese (with or with- 
out the addition of ether) between two plates of glass. We are not yet able to 
account for the origin of these peculiar discs. Mr. Busk regards the smaller 
ones as altered starch grains. It is, at all events, certain that they are not 
fangi ; and, as we shall afterwards see, that they are not peculiar to cholera. 

* It is right to state how we arrived at the knowledge of these facts. Dr. Griffith had 
pointed out to us that the bodies in question are heavy, polarize light, and are soluble 
in dikne nitric acid. He suspected that they M'ere oxalate or phosphate of hme. Mr. 
Marshall subsequently showed us that acetic acid also dissolves them readily, and that 
sul[>huric acid acts on them, producing needles of sulphate of lime. Having ourselves 
found the same bodies in the evacuations of two patients suffering from typhoid fever, 
we were examining them in company with Dr. Griffith and Mr. Marshall, when the 
demonstration of their calcareous nature reminded us of the fact that these patients had 
been taking medicine containing chalk, and, at the same time, brought to our recollec- 
tion the remark made to one of us by Mr. Topping, that Mr. Brittan's "annular bodies" 
were to be found in chalk-mixture. Accordingly, we examined a portion of medicine 
containing aromatic confection, and, afterwards, a piece of common chalk, and, in both, 
found the bodies described above, though not the larger discs which are also found in 
the rice-water fluid. Ehrenberg figures these calcareous bodies, and describes them as 
being "crystalloids," Abh. d. Akad. d. Wiss. z. Berl. 1838, p. 68. 



1850.] Cholera. - 245 

Mr. Busk thinks that the larger discs are the altered contents of bran-cells, 
Mr. Marshall, too, has independently made the observation, that certain yel- 
lowish bodies, sometimes seen, which have a thinner and narrower border than 
the fatty discs, and are merely rendered pellucid by ether, may, perhaps, be 
derived from bran. The granular masses contained in bran-cells have, how- 
ever, when undigested, no distinct border. 

4. Under the fourth class of bodies, we refer to those represented by Dr. Budd 
as the cholera fungi, undergoing decay and disintegration. They are evidently 
of a different nature from those figured by him as characteristic of the fresh 
cholera dejections. The mode of disintegration of the two classes of bodies is 
quite distinct: the so-called cholera bodies, after resisting the action of water 
for some time, break up into irregular granular masses ; whilst the decompos- 
ing bodies, depicted by Dr. Budd, seem to be, in part, homogeneous, mem- 
branous cells dehiscing ; and are, perhaps, starch cells. The rings are, most 
probably, parts of disintegrated vegetable tissue. 

It is shown by Mr. Marshall, and had before been noticed by Boehm, and 
others, that cells like fungi, or their spores, are occasionally found in the ex- 
cretions in cholera. These, however, have a more delicate structure than any 
of the bodies described as characteristic of cholera, and are totally different 
from them. It is well known that various vegetable forms are apt to become 
developed in organic fluids generally. 

From a review of the foregoing facts, it is obvious that various bodies found 
in cholera dejections have been confounded, and described as identical. It is 
also shown that many are traceable to an extraneovis source, and that even the 
discs placed in our third division are not fungi. The statement, that the bodies 
found in the cholera dejections present an endogenous multiplication, has, in 
all probability, arisen from confounding them with the uredo, or from mistaking 
the appearances produced by the small bodies seen through, or upon, the larger 
ones, or entangled in their substance. 

We are unable to identify the rings obtained from the air, and figured by 
Mr. Brittan, with any of the bodies included by him under the term " annular 
bodies.^^ Our own experiments have satisfied us that these bodies do not com- 
monly exist in the atmosphere of infected places, but the observations of Mr. 
Marshall on the dirt collected from windows and cobwebs show the great 
variety of matters which must be wafted about in the air, in the form of dust, 
and which might, in different instances, be caught with the condensed moisture. 

The bodies represented by Dr. Budd, as being found in impure drinking 
water, have the form of discs with thick edges. We have ourselves never seen 
such bodies in water. But, if it should be established that the contents of 
bran-cells sometimes assume that form, the occasional presence, in water, of 
bodies capable of being confounded with the discs derived from the discharges 
of cholera, will not appear remarkable. 

Had the bodies described by Messrs. Brittan and Swayne been proved by 
the foregoing investigations to be of fungoid nature, yet the facts we have now 
to add would have shown that they have no necessary connection with cholera. 
In the first place, they seem not to be constantly present in the discharges. It 
is, indeed, remarkable that, in those dejections which, from the absence of 
colour, have usually been regarded as the most characteristic of the disease, 
they are frequently absent. We have failed to find them in several instances. 
In one, a portion of every evacuation was set apart, and examined several times 
by each of us, and yet in no portion could we detect them , 

A still more important fact, which, from the explanations already given, might 
be anticipated, is, that all the more remarkable of the bodies which have been 
thought peculiar to cholera, exist in the intestinal evacuations of persons affected 
with other diseases. Dr. Jenner first demonstrated to us their presence, in 
great abundance, in the dejections of a patient affected with typhoid fever. 
We have since verified his observation in five other cases of this disease. We 
have also satisfied ourselves of the existence of some of the forms in dejections 
apparently healthy, from two patients in Guy's Hospital, one sutiering from 
bronchitis, the other from early cirrhosis of the liver ; and Mr. Marshall has 
detected small annular bodies " in the mucus covering the healthy excre- 



246 



Progress of the Medical Sciences. 



[Jan. 



menf of several herbivorous animals. It is obvious that bodies derived from 
such various sources will not commonly be found all present together. This, 
indeed, is not the case in cholera. The minute bodies, especially, which be- 
long to chalk will, of course, very rarely be met with, except that substance 
has been taken as medicine. 

We shall now briefly re-state the principal results we have arrived at, and 
submit the conclusion which seems to us justified by them. 

1. Bodies presenting the characteristic forms of the so-called cholera-fungi 
are not to be detected in the air, and, as far as our experiments have gone, not 
in the drinking water of infected places. 

2. It is established that, under the terms " annular bodies," "cholera cells," 
or '' cholera fungi," there have been confounded many objects of various, and 
totally distinct, natures. 

3. A large number of these have been traced to substances taken as food or 
medicine. 

4- The origin of others is still doubtful, but these are clearly not fungi. 
5. All the more remarkable forms are to be detected in the intestinal evacua- 
tions of persons labouring under diseases totally different in their nature from 
cholera. 

Lastly, we draw from these premises the general conclusion, that the bodies 
found and described by Messrs. Brittan and Swayne are not the cause of cholera, 
and have no exclusive connection with that disease ; — in other words, that the 
whole theory of the disease which has recently been propounded is erroneous, 
as far as it is based on the existence of the bodies in question. 

(Signed) William Baly, M.D., 

William W. Gull, M. D., 

Cholera Sub- Committee. 

[As highly interesting in connection with this subject, we would refer to the 
important discoveries of Dr. Leidy noticed in the American Intelligence of this 
Number.] 

56. Analyses of the Blood, Matters vomited, Alvine Evacuations, and Urine of 
Cholera Patients. — M. Becquerel examined the matters vomited in six cases ; 
the dejections in four cases ; and the blood in five cases. The results are given 
in the following tables : — 



TABLE I. SIX ANALYSES OF MATTERS VOMITED. 







Sp. 




Solid 
matter in 


Albumen 
in 


Chloride 

of 
Sodium. 


Matters 
not 


CASES. 


Reaction. 


Gravity. 


Water. 


1000 grs. 
filtered fid. 


same. 


passed 
Filter. 


1. F. set. 30. Vomited 50 




Not 






Not 






hours after attack. 


Neutral. 


taken. 


991.52 


6.37 


weigh' ble. 


2.35 


2.11 


2. M. sst. 23. Cholera of 
















8 hours' duration: iu 










Not 






midst of it vomited. 


Aeid. 


1006.03 


991.02 


7.04 


weigh' ble. 


3.08 


194 


3. M. m\. 50. Cholera of 
















£2 or 15 hours. Com- 
















meneernt. of reaction. 


Neutral. 


1012.20 


9G7.18 


2G.31 


5.11 


4.00 


6.21 


4. R ast. 42. Cholera of 
















4 days; but vomiting 
















dating only 48 hours. 


Acid. 


1015.53 


9G0.20 


31.63 


18.40 


8.24 


7.47 


5. F. set. 45. Vomited 4 
















hours before death. 


Acid. 


1017.20 


954.42 


26.68 


7.25 


5.25 


8.90 


6. F. JBl. 28. Cholera for 
















8 hours. 


Acid. 


1021.40 


931.46 


54.70 


31.50 


6.75 


11.24 



1850.] 



Cholera. 

TABLE II. FOUR ANALYSES OF THE DEJECTIONS. 



247 







Sp. 




Solid 
matter in 


Albumen 


Chloride 

of 
Sodium. 


Matters 
not 


CASES. 


Reaction. 


Gravity. 


Water. 


1000 grs. 
filtered fld. 


same. 


passed 
Filter. 


1. F !Et. 80. Cholera of 










Not 






50hrs. (Had vomiting). 


Alkaline. 


1004.20 


988.60 


8 64 


weigh'ble. 


37 


2.76 


2. M. EEt. 44. In blue 
















stage 


Ditto. 


1007.40 


979.57 


13.29 


Ditto. 


Not taken 


7.14 (with 


3. M ret. 35. Cholera of 












sep'ly. 


chlo. sod.) 


18 hours' duration. 


Ditto. 


1009.70 


781.87 


14.54 


3.22 


5.24 


3.59 


4. F. 8St. 29. Cholera of 
















18 hours' duration. 


Ditto. 


1011.04 


932.83 


15.12 


4.51 


7 81 


2.05 



TABLE III. FOUR ANALYSES OF THE SERUM OF THE BLOOD. 



CASES. 


Sp. 
gravity. 


Water. 


Solid 
Matter. 


Pure 
Albumen. 


Chloride 

of 
Sodium. 


Fatty 
Matters. 


Salts and 

extractive 

Matters. 


1. M. a3t. 29. Bled at the 
















beg. of typhoid stage. 


1041.50 


888.30 


111.70 


63.10 


12.26 


4.70 


31.70 


2. M. set. 26. Bled during 
















reaction. 


1035.10 


901.79 


98.21 


48.21 


7.38 


4.23 


38.48 


3. M. Eet. 30. Bled on the 
















morning of death for 
















cerebral congestion. 


1044.20 


893.70 


106.30 


64.20 


8.82 


Not sep. 


32,68 


4. M. set 35. Bled seven 
















hours before death for 
















cerebral congestion. 


1035.10 


[886.60 


113.40 


88.66 


Not sep. 


Not sep. 


28.74 



TABLE IV. TWO ANALYSES OF BLOOD. 



CASES. 



1. M. set. 30. Bled on the 
morning of his death. 

2. M. VEX. 35. Bled on the 
morning of his death. 



Sp. 


Solid 


to 

3 


.5 




Chloride 


Fatty 
d 

ctive 
ters. 




Gravity. 


Matter. 


o 


XI 


r1 = 


of 


«r ri i; oi 


^ 






O 


fe 


< 


Sodium. 




1074.10 


277.48 


189.60 


1.88 


51.60 


6.61 


27.59 


732.52 


1075.00 


245.05 


160.20 


0.50 


09. .35 


Not sep. 


20.00 


753.95 



First Table. — The matters vomited were, in the six cases, whitish, resembling 
rice-water, and in all respects characteristic of cholera. When filtered, they 
were separated into a solid residue left on the paper, and a perfectly transparent 
liquid, which passed through with very great ease. The former was composed 
almost entirely of coagulated albumen, having, however, attached to the frag- 
ments some minute traces of mucus. The albuminous nature of the insoluble 
fragments was demonstrated in ways such as could admit of no doubt of their 
accuracy, both chemically and microscopically.* The solid matter, after having 
been washed several times in distilled water and alcohol, was dried and weighed. 
The quantity bore a relation, as Table I. shows, to the quantity of matters held 
in solution by the filtered liquid. Another result is apparent, though less pre- 
cise. It is this : that the quantity of solid matter detained on the filter, and 
kept in solution by the liquid which passed through, was found to have dimin- 
ished, as a longer time had elapsed from the seizure. In 1000 parts of the 
liquid, the coagulated albumen varied from 1.94 gr. to 11.24 gr. The quantity 
of chloride of sodium found in the matters vomited was very great in propor- 
tion to the total quantity of matters in solution : it varied from 2.35 gr. to 8.24 

* The methods ought to have been fully detailed ; as the chemical nature of the sub- 
stance is still in dispute, and it is not to be settled by opinions, or a narrative of results. 



248 Progress of the Medical Sciences. [Jan, 

gr. Compared with the amount of this salt which normally exists in the serum 
of the blood, there was found nearly three times less. It is necessary to make 
this comparison, because the quantity of water, both in the vomitings and in 
the stools, varied greatly, and bore a proportion to the quantity of drink given 
to the patients. [The only drinks were ice and Seltzer water.] As a summary 
of the six analyses, M. Becquerel considers the ejected liquid to be the serum 
of the blood diluted by a variable quantity of water, and containing fragments 
of albumen floating in it (with a little mucus attached), and a large relative 
quantity of chloride of sodium. 

Second Table. The four dejections filtered easily, and left an insoluble mat- 
ter on the filter, perfectly analogous to the insoluble matter of the vomitings. 
Indeed, a glance at Tables I. and II. will show an identity of characters in the 
matters vomited and passed by stool; with this difi'erence, that the dejections 
were alkaline, from the presence of a small quantity of ammoniacal salts. 

Third Table. In three cases in which the blood was drawn during advanced 
reaction, coagulation took place ; in the other, this process was hardly discerni- 
ble. The density of the serum was in all the cases above the natural standard; 
the solid matters being in increased, and the water in diminished quantity. The 
chloride of sodium was nearly one-third above its normal amount. The figures 
range from 7.38 gr. to 12.2 gr., in place of from 5 to 6 gr. The fatty matters 
were more than double : and the proportion of extractive matter was enormous. 

Fourth Table. The blood flowed with difficulty. The beating required to be 
long continued to obtain the fibrin ; which was in small proportion in one case. 
The difference between the amount of fibrin in the two cases cannot be explain- 
ed. The large proportion of globules in both cases is striking. 

Remarks on the Facts contained above. M. Becquerel considers that, in cholera, 
it is undeniable that a certain quantity of the serum and solid constituents of 
the blood, especially of the albumen, is exhaled through the mucous membranes. 
The presence of coagulated albumen is probably the result of diminished alka- 
linity in some dejections, and the neutral or acid reaction of others. The 
cause of the abundance of chloride of sodium cannot be explained. There is 
less water in the blood, on account of the quantity thrown off from the intes- 
tines ; and this occasions a relative concentration of the globules, of the chloride 
of sodium, of the salts, and extractive matters. The notable diminution in the 
albumen of the serum is explained by its presence in the intestinal discharges. 
The almost triple amount of fatty matters must be attributed to the rapid waste 
or absorption of fat, which takes place in cholera. 

The Urine. Six cases are thus briefly given. 

Case i. A man (hospital patient) was seized all at once with the severe 
symptoms of cholera, and died in twenty-four hours. No urine was passed, and 
none could be obtained by the catheter. 

Case ii. A young man, aged 17, was treated at home by M. Becquerel, and 
died on the fifth day. On the tAvo first days, he was catheterized, but no urine 
was obtained. On the third, fourth, and fifth days, he passed urine spontane- 
ously ; and on none of the days did it contain any trace of albumen. 

Case hi. A young man died in hospital, on the sixth day, in a typhoid state. 
On the first day, no urine was obtained by the catheter ; on the second and third, 
a little was got ; and on the fourth, fifth, and sixth, he passed urine spontane- 
ously. In the urine of none of the days was it possible to detect any trace of 
albumen. 

Case iv. A patient, labouring under disease of the heart, was attacked by 
cholera in a mild form, and without suppression of urine, which was never found 
to be albuminous. 

Case v. A man came into hospital with intermittent fever, was seized with 
malignant {foudroyant) cholera, and died in twenty-four hours. Half a tea- 
spoonful of urine was got by the catheter. It did contain albumen, but in so 
small a quantity as to make its presence almost matter of doubt. 

Case vi. A patient was brought into hospital eight or ten hours after seizure. 
By the catheter, urine was obtained on the first, second, and third days ; it was 
small in quantity, turbid, acid, and contained a very notable quantity of albu- 
men. On the fourth and fifth days, he passed a little water spontaneously, which 



1850.] Cholera. 249 

was nearly devoid of albumen. He was now well ; and on the sixth day there 
was no trace of albumen in his urine. 

From these cases, M. Becquerel concludes: — 

1. That, in a considerable number of cases, it is impossible to obtain urine 
from cholera patients. 

2. That, in cases of great and of medium intensity, the urine may contain no 
trace of albumen. 

3. That, in certain cases, from the return of the secretion up to convales- 
cence, it is persistently albuminous. 

M. Becquerel's negative observations on the urine are of importance, as they 
are quite sufficient to render the presence of albumen in it by no means a diag- 
nostic sign, as to any case of serous purging being, or not being, cholera. It is 
within our own knowledge that many others, besides M. Becquerel, have in 
vain searched for albumen in the urine of cholera patients. As we know that 
albumen does not, in any disease, appear in the urine unless the kidneys are 
congested, the presence of albuminous urine in cholera is, evidently, though a 
common, only a contingent symptom. The exhalation of albumen from the 
gorged capillaries of the intestines is a more important and characteristic phe- 
nomenon. The observations of M. Becquerel tend to strengthen the opinion 
that the ^'rice-water" fluids, vomited and passed by stool, are alike hemorrhage. 
This fact ought never to be lost sight of in the treatment. By bearing it in 
mind, a physician, apt in his resources, will save more patients than could be 
rescued by any specific.^ — London Journ. of Med., Nov. 1849, from Arcliives 
G^n^rales de Med., Oct. 1849. 

57. Ohservations on the Urine in Cholera. By James W. Begbie, M. D. 
{Monthly Journ. Med. Sc., Nov. 1849). — One of the most invariable and character- 
istic symptoms of Asiatic cholera is the entire, or almost entire, suppression of 
urine; the examination, therefore, of the characters presented by that secretion, 
at its restoration after cessation of collapse, is highly important. The mode 
of fatal termination, in man}'' cases of cholera, has satisfactorily shown that the 
retention of those matters in the system, which it is the province of the kidneys 
to eliminate, may be regarded as one of great danger to be apprehended, and, 
if possible, avoided. That this danger is not equally imminent in all cases in 
which the urine is suppressed, we know, and that it should not be so, we can 
easily understand ; for chemical examination of the fluids passed from the 
bowels has pointed out, that, after the kidneys have ceased to perform their 
function, the urea may find an exit by the intestines. After a time, however, this 
channel fails, and the morbid matter being retained, death in the way adverted to 
is rendered almost certain ; or, at all events, the case presenting these features 
assumes a still more alarming aspect. That death, in the way of coma, attributed 
to this cause, should take place so much more rapidly in cholera than in any 
other disease, is, Dr. B. thinks, to be accounted for in the fact, that the nervous 
prostration, prior to the occurrence of symptoms threatening coma, has been 
excessive, and that consequently the action of even a smaller amount of morbid 
matter is rendered more speedy and certain. 

Through the kindness of Dr. Bobertson, physician to the Cholera Hospital, 
Dr. Begbie has had ample opportunities for making repeated and careful ex- 
aminations of the urine in this disease. From these examinations, tables of the 
various characters and phenomena presented by the urine were formed. The 
tables were placed at the disposal of Dr. Robertson ; what is now to be said in 
regard to the urine being deduced from these records by Dr. Begbie. 

" The urine examined was, as a general rule, that first passed by the patient 
after recovering from a state of collapse. In one or two instances, the urine was 
withdrawn by the catheter during life, and, in a few, by the same means after 
death. The characters presented by the urine I shall notice in succession, and 
on some of these, in concluding, ofi'er a few observations. 

" 1st. As to the appearance and other external characters. The amount was 
almost invariably small ; on several occasions, so small as to prevent the density 

* Vide Reports of Westminster Society, pp. 1076 and 10S2, 



250 Progress of the Medical Science. [Jan. 

of the fluid being ascertained. The appearance of the urine varied greatly, 
and no accurate statement can possibly be made as to the most common colour. 
A large proportion of the urines deposited a distinct sediment ; others were 
muddy and opaque, but presented no evident deposit ; very few were perfectly 
translucent. The odour was not characteristic ; in a few, it was ammoniacal. 

" 2d. The average density was considerably lower than that of healthy urine ; 
for, though it varied greatly in different cases — the highest examined being 
1.045, and the lowest 1.007 — the largest number were at 1.012, and the succeed- 
ing at 1.016, 1.018, 1,020, and 1.014. Of twenty-two specimens, the densities 
of which were ascertained more than once, in five the specific gravity had risen 
a few degrees at the second examination, in nine it had fallen, and in eight it 
continued the same ; while, in two of the nine, it is noted that, at the third ex- 
amination, it had again increased. 

" 3d. In thirty-seven out of seventy-two specimens, in which the reaction of 
the urine was ascertained, it was noted as acid; in nineteen, it was strongly, 
highly, or powerfully acid ; in three, it was faintly acid ; in seven, it was neutral ; 
in four, it was alkaline ; and in two strongly, highly, or powerfully alkaline. 
On subsequent examinations of several of these urines, the reaction was found 
unaltered ; while, in one or two of those which presented, at first, an acid re- 
action, it was found to be neutral or alkaline ; and, on the contrary, in a few of 
those in which, on first examination, the reaction had been alkaline, it had be- 
come acid. It is worthy of note that, in at least one of the latter class, the urine 
was, in the first instance, withdrawn by means of the catheter, symptoms of 
retention having manifested themselves ; in this there probably existed a suf- 
ficient cause for the alkalinity of the urine. 

" 4th. Of sixty-seven urines tested for the presence of albumen, by the applica- 
tion of heat and the addition of nitric acid, in sixteen the urine was noted as 
being coagulable, or decidedly coagulable ; in seventeen, as being highly or 
powerfully coagulable ; in twenty, as slightly or faintly, or very slightly or very 
faintly, coagulable. In fourteen, there was no Goagula]3ility. 

" In a number of those in which albumen existed, subsequent examinations 
were made, at an interval of one or two days, with the effect of finding that, at 
the second examination, in most it had partially disappeared, and that in very 
few it was present on the third. In one or two instances, the first urine voided 
was not coagulable, but a subsequent examination detected a very small amount 
of albumen. In all, the albumen, though present at the first examination, even 
in large quantity, was but transient in its duration. 

" 5th. In twenty-eight out of sixty-eight specimens, it was noted that bile ex- 
isted, or was decidedly present, or that its existence was characteristically dis- 
played upon adding a few drops of nitric acid. In fifteen others, there existed 
a slight trace of bile, or an equivalent term was used in expressing its presence. 
In twenty-five, the addition of nitric acid gave no indication of the existence of 
bile. In several, bile was found on subsequent examinations, and in two was 
found to manifest its presence for the first time on the third examination. In 
most, though undoubtedly present, its duration, like that of the albumen, proved 
short. 

" 6th. In eighteen specimens of urine, the amount of urea present was ascer- 
tained. The mode adopted was the following : A thousand grains of urine 
were first accurately weighed, and then evaporated to the consistence of an 
extract, to which alcohol was added, and after thorough digestion had been 
allowed, the alcoholic solution of urea thus obtained was filtered and then 
evaporated. To the mass left nitric acid was added ; the nitrate of urea was 
thus formed, and being collected on a filter, was carefully weighed. In eight 
out of the eighteen urines, however, in which this process was adopted, it was 
found impossible, from its extreme minuteness, to estimate the amount of urea 
present ; accordingly, in regard to six of the eight, it is noted that there did not 
exist suflScient urea to crystallize with nitric acid ; and in regard to the other 
two, that there remained of the nitrate of urea a mere trace upon the filter. 
These eighteen specimens were the only ones in which I attempted to estimate 
the exact amount of urea contained; but, in a large number of the urines ex- 
amined, the usual method for arriving at an approximation as to the contained 



1850.] Cholera. 251 

urea was practiced, namely, by gentle evaporation and the addition of nitric 
acid. In all the urines treated in this manner, the urea^ was found to be deficient 
in quantity. In the ten specimens, the weight of the nitrate of urea obtained 
was as follows : In one, 28 grains ; in one, 20 grains ; in two, 19 grains ; in 
one, 18 grains; in one, 11 grains ; in one, 10 grains; in one, 9 grains ;t in one, 
8 grains ; in one, li grains. 

"From these results, it appears that, from none of the urines, the urea in which 
was made the subject of quantitative analysis, was there obtained of the nitrate 
an amount equal to that of the ureaj contained in healthy urine. 

" 7th. The microscopic appearances presented by the urine in sixty-four in- 
stances were noted. In two of the sixty-four, no deposit of any kind existed. 
In regard to the remaining sixty-two, it is noted that, in fifty, epithelium existed 
in greater or less amount. In fifteen of these, it was present in very large, in 
three in very small quantity. In twenty-four urines the casts, or epithelial 
moulds of the small tubes of the kidney, were present ; while in almost all the 
specimens examined, an appearance resembling these tubes, as if lacerated or 
broken up, existed. Amorphous urate of ammonia was present in fourteen 
cases ; in one or two others, the urate of ammonia evidently existed in a crys- 
talline form. Besides it, the crystalline deposits met with were — the uric acid, 
the ammoniaco-magnesian phosphate, and the oxalate of lime. The former was 
present in sixteen instances, the triple phosphate in twelve, and the latter in 
four : in three of these the dumb-bell was the form assumed ; in only one the 
octahedral. In two urines blood-corpuscles, and in other two, pus-corpuscles, 
existed, all in small quantity, and all in the cases of females, so that, in all pro- 
bability, their presence depended on the existence of some vaginal or uterine 
discharge. 

" Exudation corpuscles, or the compound granular cells, were present in three 
urines. In one of these, the patient, at the period of her seizure with cholera, 
was just convalescing from a severe attack of pneumonia. These granular cells 
are very commonly met with in the urine, about the critical period, in acute " 
inflammation of the lung. With the history of the other two patients in whose 
urine these cells were found, I am unacquainted. Spermatozoa and the sper- 
matic globules were detected not unfrequently in the urine, when drawn off, by 
means of the catheter, from the dead body. In one instance in which dissection 
was performed a very short period after death, the animalcules appeared living : 
the urine in which they moved was of acid reaction, and in this respect confirmed 
an observation I have frequently had occasion to make, that the acidity of the 
urine is favourable, and its alkalinity unfavourable, to their vitality. In this 
way the preservation of their life in urine containing pus (according to some 
authors, the only urine in which their vitality can be continued for any time), 
may be accounted for ; such urine is almost invariably acid ; on the other hand, 
urine containing much mucus, in which these animalcules are never found liv- 
ing, may reasonably be supposed to offer as secure a retreat to them as the 
former, but that urine is invariably alkaline. 

" From these details of the examinations of a large number of specimens of 
urine in cholera, it appears that, besides being at first entirely absent, or greatly 
diminished in quantity, when the secretion is again restored, it is very ma- 
terially changed as to quality. It is of a lower specific gravity than healthy 
urine, and though its reaction is generally acid, it for the most part contains 
abnormal ingredients, of which the chief are albumen and bile, with a greater 
or less amount of perfect and abortive epithelium, derived from different parts, 
and assuming also different forms ; and besides containing abnormal ingredients, 
one of its own principal constituents is absent, or exists in very limited amount. 

* The reader will remember that the amount of urea in healthy urine is 30 grains in 
1000 of urine. To test the accuracy of my own experiments in estimating the exact 
amount of urea in cholera urines, I, at the same time, conducted the examination of the 
urine in other diseases as well as in health, and as the results were uniform, I think the 
table given above is worthy of confidence. 

t This analysis was conducted by Dr. Douglas Maclagan. 

X According to M. Regnault, 100 parts of the nitrate should contain 4S.93S of urea. 



252 Progress of the Medical Sciences. [Jan. 

It is this absence or deficiency of urea, the consequences of which are known to 
us, and are represented in cholera, and in other diseases also, by what are now 
regarded as very evident signs, which is the only truly important morbid con- 
dition of the urine ; the abnormal ingredients present are of interest as in- 
dicating an alteration in the quality of the urine, but only of importance when 
taken in connection with this. In the present paper, however, the changes 
alluded to merit a little more of detail. It is, I think, of interest to observe 
the circumstances with which the presence of albumen in the urine of cholera 
is attended ; generally bile co-existed with it, if not throughout its entire dura- 
tion, at least at its commencement, or before its disappearance ; further, albu- 
men was always associated with, and in general held a ratio commensurate 
with the amount of epithelium found on microscopic examination. Taken in 
connection with the former, its presence, as indeed that of the secretion itself, is 
an indication of a most favourable tendency, nothing less than that of commencing 
convalescence, the bile almost always manifesting its presence in the urine at 
the period when it re-appeared in the stools. No urine which contained albumen 
did not contain epithelium ; and, on the other hand, no urine in which epi- 
thelium was present in any amount, was destitute of albumen : further, as the 
albumen disappeared, so also diminished the epithelium. This association of 
albumen and the cells of epithelium is exactly what we observe in the urine of 
certain other diseases ; of scarlatina, for example, from which, at a particular 
period of the disease, neither, I believe, are ever entirely absent ; and though 
variety, to a considerable extent, exists in the amount of both present, they 
uniformly exist in corresponding ratio. The presence of epithelium in the urine 
of cholera is the evidence of the existence of a process of desquamation, to 
which the mucous membrane lining the urinary passages is subject, equally 
with that which lines the intestinal canal, from which desquamation, to a 
considerable amount, occurs. When such changes are taking place in the 
epithelium lining the small tubes of the kidney, the office of the cells composing 
which is to eliminate from the blood the matters which, in the normal state of 
the renal function, form urine it is not surprising, that albumen and bile, in 
greater or less amount, should find their way into that secretion, and that the 
urea it contains should be at first so deficient in quantity. In but few instances 
did the two former continue to manifest their presence in the urine for more 
than a few days at most, while, as a general rule, the lapse of the same period 
was sufficient for the increase in the urea to have taken place, if not to the nor- 
mal standard, at least to a point not far distant from it. 

" Frequent observations on cholera urine have shown me that the uric acid is 
not generally deficient in quantity ; this was proved by microscopic examination, 
as well as by the addition of a small quantity of nitric acid, when the usual 
change in appearance, illustrative of its presence, occurred. Under the micro- 
scope, the usual form presented by the uric acid was that of small lozenges ; 
generally, they were void of colour, but occasionally possessed a deep yellow 
hue. The crystals of the triple phosphate were always present when the urine 
was alkaline — they possessed their usual form. Crystals of oxalate of lime 
were only observed four times ; it was not ascertained whether the patients, in 
whose urine they occurred, presented the symptoms which are known to accom- 
pany the presence of this salt in the urine, and this incjuiry was not deemed 
necessary, for we know that the oxalate frequently appears unassociated with 
any dyspeptic symptoms. The observation of Dr. Prout, that, during the pre- 
valence of cholera in 1832, the oxalate of lime was more frequently present than 
before or after the epidemic, has not been confirmed, at least in the case of 
hospital patients, during the existence of cholera in Edinburgh. From nu- 
merous observations, conducted with the intention of estimating the relative 
frequency of the various urinary deposits, I have f)und that crystals of oxalate 
of lime occur as frequently in the urine of hospital patients in Edinburgh, as 
either of the other common crystalline deposits. Oxalate of lime is very common 
in the urine of patients labouring under all the forms of organic disease in the 
abdomen, with the exception of that of the kidney. The same observations 
showed that no increase in the frequenc}^ of the occurrence of oxalate of lime 
took place during the epidemic of cholera. 



1850.] Cholera. 253 

" On a review of these observations, the following conclusions, in regard to the 
urine passed during recovery from cholera, may, I think, be deduced: — 

" 1st. That the urine, besides being affected as to quantity, is materially altered 
in quality. 

" 2d. That this alteration consists in the presence of a very small quantity, or 
in the entire absence of urea, and in the presence of albumen and biliary colour- 
ing matter. 

" 3d. That, on examination by the microscope, there will be found uniformly 
associated and existing in amount commensurate with the albumen, epithelium 
assuming different forms, and derived from different parts of the urinary 
system. 

" 4th. That one or other of the following deposits will probably be present — 
amorphous urate of ammonia, uric acid, ammoniaco-magnesian phosphate, or 
oxalate of lime — the two latter being less frequently present than either of the 
former. 

" 5th. That the healthy condition of the urine, in so far as the increase in the 
amount of urea, and the disappearance of the albumen and bile, are concerned, 
is generally restored in the course of a day or two, if the case go on favourably. 

" 6th. That, as the association of albumen and bile, in particular, as well as the 
other general characters of the urine which have been stated to exist, is by no 
means of common occurrence, it follows that the careful examination of the 
urine in cholera is of importance both in diagnosis"'^' and practice. f 

" To which I feel disposed to add another conclusion, though it is not brought 
fully out in the preceding observations. 

" 7th. That the characters which have been stated to be those of cholera urine, 
will be always best marked in the severest cases. '^ 

58. On the Non-existence of Bile in the Stools of Cholera, and in the first Urine 
secreted after the Algide Stage. — Prof. Parkes formerly doubted whether the 
peculiar violet, pinkish, or purplish colour which is frequently produced in the 
rice-water stools of cholera, by the action of a small quantity of nitric acid, 
and in a less degree by hydrochloric acid, when aided by heat, was to be attri- 
buted to bile ; but additional inquiries have led him to believe that the substance 
giving this reaction is " modified bile,'^ as stated by Simon. "In a perfectly 
healthy stool, ^^ Prof. P. states that he has "lately obtained this violet reaction 
instead of the ordinary evidence of bile. I have found a similar tint almost 
invariably in the liquid stools of typhoid fever, and occasionally in those of 
typhus fever. And, as I have at present been able to find no evidence that nor- 
mal or morbid pancreatic fluid, or any exudation from the intestinal mucous 
membrane, can give this reaction, I infer that it is attributable to bile. I have 
not been able to discover the cause of this peculiar, though, as it has occurred 
in a perfectly healthy stool, not abnormal, condition of the bile. It is not owing, 
as might be supposed, to excessive dilution, which might permit the bile-pig- 
ment to be acted on so rapidly by the nitric acid, that the green tint would be 
only momentarily seen, and would pass at once into one of the colours which 
in healthy bile succeed to it, and which might be conceived to be more stable. 
For, if the bile of cholera, as of any other disease, be diluted to the utmost ex- 
tent, so that only the slightest tint is given by nitric acid, still that tint is in- 
variably green ; and if the solution is as dilute as it can be to give any colour 
at all with nitric acid, an excess of acid destroys the green colour without any 
transition tints. Possibly, as Simon supposed, the bile-pigment may become 
oxidized, or otherwise altered by the fluids with which it is mixed, or some 
normal constituent of the bile may be present in unusual quantity, while the 

* I have made frequent examinations of the urine in diarrhoea, and in the so-called 
choleroid diarrhoea, but have never found albumen and bile associated with epithelium, 
and a small amoutjt of urea, to be the characters of such urine. 

t Dr. Robertson prescribed colchicum in a case where a small quantity of urine, de- 
ficient in urea, was voided, and with the desired effect upon the urine, and with great 
benefit to the patient. 

No. XXXVII.— January, 1850. 17 



254 Progress of Hie Medical Sciences. [Jan, 

common bile-pigment may be at the same time deficient. Whatever be the 
nature of this substance, it gives no reaction with sugar and sulphuric acid. 

"But, although this violet and pink tint can be obtained from many cholera 
stools in the earlier stage and in the milder cases, it cannot generally be pro- 
cured from the fluid passed during the greatest height of the intense disease. 
So that at this period there is probably complete retention of bile ; at any rate, 
there is no evidence whatever, that I can discover, of any passage of bile into 
the canal. 

'* In the first urine passed after the cold stage, there is generally a large quan- 
tity of a substance which gives the same characteristic colour with nitric acid. 
Whatever may be in other respects the condition of the urine, or of the fluid 
which represents it, more or less of this modified bile is present, and can be 
readily detected by nitric acid, either at once or by forming an alcoholic solu- 
tion of the extract. Thus I have found it in a fluid, drawn from the bladder 
after the cold stage, in a case in which there was no further secretion. This 
fluid, about ^i in quantity, was almost like cofice grounds, from the presence 
of a great number of blood-particles ; it contained, of course, albumen, but no 
urea, and gave, with nitric acid, a deep violet colour, passing into a blackish 
purple. In other cases in which the urine has been transparent, yellow acid, 
without urea, or with mere traces, and containing albumen, the substance has 
been present in variable quantities. In one case, I found it in urine which 
contained not a trace of albumen, but so much of this modified bile that the 
colour given by nitric acid appeared almost black by reflected light; there was 
also some urea, but the quantity was not determined. In another case, I found 
a large quantity of albumen, with a mere trace of this substance ; so that the 
manifestation of this substance did not seem connected with the appearance 
either of blood-particles, albumen, or urea. It seemed to pass off much more 
rapidly than the urea, and speedily disappeared when the urinary secretion 
was re-established, although the urea did not, for some little time, reach its 
normal standard. In the urine, as in the cholera stools, this substance seemed 
to be nearly destitute of colour till nitric acid was added. If there was any 
sediment in the urine, either of exudation or pus-corpuscles, phosphates, epi- 
thelium, casts of tubes — or, at a later date, of uric acid, urate of ammonia, or 
of soda — this substance gave them no colour. Its alcoholic solution rapidly 
decomposed, so that, in three weeks or a month, the characteristic reaction was 
almost or entirely lost. 

" I believe this substance to be the same with that present in the cholera stools, 
for the following reasons : — 

"1. In both cases, the substance is soluble in alcohol. 

" 2. In both, a most peculiar violet or pink tint is given by nitric acid to the 
alcoholic solution. 

**3. In both, an excess of acid destroys the tint, and produces a light yellow 
colour. In the cholera stools, sometimes a shade of blue can be obtained after 
the violet ; and in the urine sometimes a shade of green precedes the violet or 
puce colour. 

" 4. In both cases, if albumen be present, and be coagulated by heat and nitric 
acid, it is tinged of a red or violet colour, unless too much acid be added. 

" I have not yet succeeded in satisfactorily detecting this substance in the 
blood. It is possible that it will shortly be found there. 

" This substance is by no means peculiar to the urine of cholera. I have found 
it in the urine of various diseases. In Bright's disease occasionally, as noticed 
by Heller; in some obscure abdominal affections without albuminuria; in a 
case of abscess of the liver ; in one of cholecystitis ; in two cases of dysentery 
(although in the greater number of cases of dysentery it is not present) ; and 
in a complicated case of purpura, rheumatism, and Bright's disease. In these 
cases, the urine was generally clear, pale, acid, or neutral, and quite different 
from very dilute common icteric urine, which gives the ordinary reaction of 
bile-pigment. 

" I believe, for reasons which will be more fully considered at another time, 
that this substance has been described by Heller as a normal urinary colouring 
matter, under the name of uroxanthin. Uroxanthin, with nitric acid, gives 



1850.] Cholera. 256 

the pink tint, and passes first into urrhodin, and subsequently it passes into 
the blue uroglaucin. I believe these changes may sometimes be followed in 
cholera stools, with which not a particle of urine has been mixed. So, also, 
I believe, that this modified bile has been included by Dr. Golding Bird in 
liis description of purpurine, although it does not altogether correspond to this 
substance. But it would be foreign to the object of this note to pursue the sub- 
ject further at this time." — MontJily Journ. of Med. Sciences, Oct. 1849. 

59. Abstract of Observations made in the Cholera Hospital at Leyden, during 
November and December, 1848, and January, 1849. By Dr. F. J. J. Schmidt. — 
From the 7th of November, 1848, to the 3d of January, 1849, 146 patients were 
received into the hospital — 82 males, and 64 females. Forty-nine of the patients 
were under fifteen years of age. The youngest admitted was two years and 
a-half old, the oldest seventy-two. With the exception of ten persons, who were 
sufiering merely from ordinary diarrhoea, all were afiected with genuine Asiatic 
cholera. The greatest number were admitted towards the end of November, 
and the first half of December. All were of the lowest class ; workmen, la- 
bourers, beggars, &c. ; and all, except three, inhabitants of Leyden. It could not 
be ascertained that any of them had been attacked during the epidemic of 1832. 

Many of those who were not carried ofi" by the cholera were attacked with 
consecutive diseases — by far the most frequent of these being typhus. 

Few of the patients could give any clear account of premonitory symptoms ; 
and very many described their health to have been perfectly good just previous 
to the attack. Excesses of various kinds could not be traced as the exciting 
cause, nor was it observed that more patients were admitted after Sundays and 
festivals. Exposure to unusually wet weather seemed to have more influence. 
Afi instance of this was furnished by a beggar, who went out on a very rainy 
morning in good health, wandered about all day, and was brought dripping wet 
to the hospital, at nine in the evening, in the worst state of collapse ; he died 
early the following morning. 

None of the numerous hospital attendants were attacked with the disease. 

There was much variety in respect of the duration of the illness. The shortest 
periods were eight and nine hours ; both fatal cases. The occurrence of hiccup 
during the attack was usually a fatal sign; a fact in direct opposition to the 
statements of several German writers. 

In two women, who were suckling at the time of their being attacked, the 
mammae became completely collapsed during the acute stage. With the first 
signs of reaction they began to swell, soon became turgid with milk, and, when 
reaction had fully set in, were so distended and painful, that it was necessary 
to draw off the milk several times. In both patients, this was done twice be- 
fore the secretion of urine had been re-established, and in one of them before 
the feces had begun to be coloured with bile. The milk was very thin, of a 
light green tint, and became of a more decidedly green colour in the course of 
a few days. Chemical analysis demonstrated the presence of uric acid in it 
before the secretions of urine had set in. The colouring matter of bile could 
not be detected by the ordinary tests, so that the cause of the greenness was not 
ascertained. In the last-named patient, the milk first secreted was found to be 
composed as follows : — 

1000 parts contained — 

Water, ------ 

Solid matter, - - - . 



Casein, 

Butter, 

Sugar of milk, 

Extractive matter, 

Salts, 

Urea, 



917.007 
82.993 


8.714 
2.919 


71.223 


0.127 

82.993 



The milk, when fresh, was neither acid nor alkaline ; its specific gravity was 
1028.3, healthy milk having a specific gravity of 1028 to 1042. 



256 Progress of the Medical Sciences. [Jan. 

The bodies of all the seventy-three patients who died were examined, at from 
twelve to thirty-six hours after death; none at a later period. In all cases 
where death had occurred in the acute stage, it was noticed that a remarkable 
elevation of temperature took place immediately after death. Bodies which, 
long before that event, and up to the last breath, felt as cold as corpses, and 
which the thermometer proved to be several degrees below the temperature of 
the surrounding air, showed, a few minutes after death, a very sensible increase 
of warmth, whether they were laid in a cold place and covered merely with a 
sheet, or remained covered up in blankets. In either case, this increased warmth 
was retained for several hours, and they did not become as cold as ordinary 
corpses until the expiration of twelve or .sixteen hours. It is worthy of notice 
that the bodies were generally found to a great extent free from the traces of 
previous acute or chronic diseases. This remark fully applies to the old sub- 
jects. In no one instance were decided tubercles found ; and only in very few 
cases trifling earthy deposits in the upper lobes of the lungs, surrounded with 
condensed tissue. Carcinoma did not once occur in any organ. 

Cranium and Vertebral Canal. — In the cases of pure cholera (uncomplicated 
with typhoid symptoms), the universal congestion of the veins and arteries, 
described by some authors, was by no means constantly observed. This con- 
dition was only noticed in the vessels and sinuses at the base of the skull. In 
only about one-fourth of the cases were the membranes of the brain much 
injected, and its substance hardly ever ; so that a section of it exhibited no more 
than the ordinary number of bloody points. In about half the cases, the arach- 
noid was thickened, whitish, and opaque, and easily separable from the convo- 
lutions, the result of serous exudation. The quantity of fluid in the ventricles 
varied greatly, and seemed to bear no proportion to the duration of the disease. 
The same remark applies to the consistence of the brain itself. 

The spinal cord and its membranes were examined in two bodies only ; 
nothing remarkable was found in either case. 

Thorax. — The larynx, trachea, and bronchi, the pharynx and oesophagus, 
presented nothing worthy of note. The only morbid condition found in the 
lungs was ''oedema,'' which existed in the majority of cases of pure cholera 
where much dyspnoea had preceded death. The rarity of tubercular disease has 
been already noticed. 

The heart and great vessels usually contained a large quantity of blood, the 
condition of the latter varying considerably. In most cases of pure cholera, no 
fibrinous coagula were to be found, but the cavities of the heart were distended 
with thick blood, in which large black clots had formed, extending into the 
great vessels, and easily giving way when an attempt was made to draw them 
out. Occasionally, these clots were mixed with small shreds of pure fibrin. 
The arteries more remote from the heart were entirely empty ; the veins con- 
tained more or less blood, dark of colour, and of ropy consistence. 

Abdominal and Pelvic Cavities. — The absence of all unpleasant smell on 
opening the abdominal cavit}^, which many have asserted to be characteristic of 
cholera subjects, was by no means universal. In several cases, the odour was 
most disagreeable. The abdominal viscera, for the most part, presented the 
general condition and aspect which have been often described. In adults, the 
distended pale stomach, the turgid gall-bladder, projecting beyond the margin 
of the liver, the inflated ascending and descending colon, the contracted trans- 
verse portion, and the deeply injected small intestines and omentum, were 
strikingly evident. The quantity of matter contained in the alimentary canal 
depended, of course, on the greater or less amount of diarrhoea which had 
taken place ; like the dejections during life, it was colourless, and, where the 
illness had run but a short course, mixed with undigested food. Tympanitis 
was rare in the small intestines, but more frequent in the ascending colon. 
The stomach usually contained, in addition to a larger or smaller quantity of 
the matters above-mentioned, a considerable bulk of air. In by far the greater 
number of cases, its mucous membrane might be termed normal, of a light red- 
dish colour, often covered with a tenacious mucus, easily wiped off. The larger 
scattered glands could be noticed as white, prominent points in only two or 
three cases. General or partial injection of the mucous membrane was not 



1850.] Oholera. 257 

observed ; but, occasionally, small, circumscribed, round extravasations, resem- 
bling petechias in appearance. 

Duodenum. — In this intestine, as in the other small intestines, vascular in- 
jection was rarely noticed. Brunner's glands were frequently found enlarged, 
from the size of a pin's head to that of a lentil. This condition, however, did 
not exist in patients who had died typhoid. 

Ileum and Jejunum. — In this portion of the alimentary canal, the greatest 
variety of appearances was manifested, from extreme anaemia to a high degree 
of vascular injection; the glands, in some cases, undistinguishable, in others 
offering the most marked specimens of " infarctus," and these varieties having 
no apparent relation to the intensity or duration of the disease. In children, 
the mucous membrane was usually pale and bloodless, but frequently of the 
normal reddish colour. In other cases, there was considerable injection of 
the vessels along the free portion of the intestine: the highest degree of injec- 
tion, in which the mucous membrane assumed a deep red, from the multitude 
of gorged capillaries, was extremely rare. In two or three instances only did 
circumscribed extravasations — petechias — occur. The above remarks, as to the 
vascular injection of mucous membrane, apply equally to the typhoid cases ; 
but in the latter the contents of the intestines were, of course, different in their 
character. In a very few instances, no trace of glands could be seen throughout 
the whole course of the intestines. The glandulae solitarise, and Peyer's glands, 
were sometimes barely discernible, as in ordinary post-mortem examinations ; 
at one time they would be found a little raised above the level of the mucous 
membrane ; at another, the glandulse solitarias would be as much developed as 
those in the duodenum, while the number, extent, and "infarctus'^ of Peyer's 
glands presented the appearance described by authors as " plaques intestinales.^' 
This enlargement was by no means equal in both sets of glands ; the largest 
" plaques'' t3eing sometimes seen where there was not a trace of solitary glands, 
and vice versa. In patients who died typhoid, the glands were usually found 
normal in appearance ; ulcerations of Peyer's glands being nowhere met with. 

Large Intestine. — The partly distended and partly contracted state of the colon 
has been already noticed. Its contents were in all respects similar to those of 
the small intestines ; the mucous membrane was, in most cases, normal, and the 
glandulse solitarise rarely enlarged. Except in a few bodies, where there were 
traces of old dysentery, morbid appearances were found only where bloody 
stools had preceded death ; in such patients, the mucous membrane was more 
or less injected, sometimes so deeply as to be here and there black, the contents 
of the bowel being also mixed with bloody exudation. 

The Liver was always unchanged in structure and colour (with the exception 
of a few specimens of fatty degeneration, and of earthy deposits) ; the vessels 
filled with dark blood. The biliary ducts were almost always greatly enlarged, 
filled with thick, green bile, which was infiltrated into the surrounding paren- 
chyma of the liver. The distension of the gall bladder was considerable, but 
varied in different subjects. The bile itself offered every variety of appearance. 

Neither in the Spleen nor the Pancreas was any change observable. 

The only circumstance worthy of notice in the Kidneys was the large quan- 
tity of mucous fluid which could generally be made to exude from the pyramids 
by pressure. Sometimes this fluid was to be found also in the calices and pelvis 
of the kidneys ; and when this had been washed away, a few drops might still 
be squeezed from the uriniferous tubes. Under the microscope, this fluid ap- 
peared to consist wholly of pus cells and epithelium, without any trace of crys- 
tals. It had no urinous odour. 

The Bladder always presented the appearance described by those who have 
written on the subject, being extremely contracted, quite empty, and showing 
no trace of vascularity, with the exception of a circle of fine vessels around 
the neck. 

Nothing remarkable was detected in the Genital Organs, Nervous, or Muscidar 
Structure. The muscles were usually hard or dark-coloured, having much the 
appearance of smoked meat. — Monthly Journal, Nov. 1849, from Kliuick, vol. iv. 
p. 525. 



258 Progress of the Medical Sciences. [Jan. 

60. Calomel Treatment of Cholera. — Dr. H. M. Hughes, Assistant Physician 
to Guy's Hospital, gives a very unfavourable report in a paper in Lond. Med. 
Gaz. (Sept. 21, 1849), of the effects of the calomel treatment of cholera, as 
resulting from his experience. Most of the cases he has seen have been in 
consultation. In a majority of these, the disease had already advanced, when 
he first saw the patients. " But,'^ he says, " I have been called to cases in which 
calomel, in frequently repeated small doses, had been commenced very soon 
indeed after the onset of the complaint, and to one in which it was administered 
an hour and a half after the first appearance of the disease, and assiduously 
continued up to a quarter of an hour of the patient^s death ; which event 
occurred only fourteen hours after he had been perfectly icell. I have seen a 
great many cases in which the frequently repeated small doses of calomel, and 
some few in which large doses less frequently administered, had been com- 
menced, and actively persisted in, before I had been called in. With such 
administration of the mineral, when the patient was already in, or approaching 
to, a state of collapse, I have not usually interfered, for I have considered that 
it was not likely to be then injurious, and have contented myself with advising 
the free supply of cold fluids or of ice ; the application of wet towels wrapped 
round the legs, for the relief of cramps : sponging the body with tepid water, 
and then covering it with blankets : and the use of any mild nourishment that 
the patient could take, with a sparing supply of stimulants, preferring others 
to alcoholic stimulants. I believe that all, or at any rate almost all, the patients 
so treated have died.'^ 

Dr. Hughes further states that a number of his professional friends made to 
him equally unfavourable reports of the results of their experience with the 
calomel practice. 

Dr. W. L. Richardson, physician to the cholera hospital at Edinburgh, has 
been equally unsuccessful with the calomel treatment. In the Medical Times 
(Sept. 22, 1849), he gives a tabular statement of eighteen unequivocal cases of 
Asiatic cholera, treated at the Edinburgh Cholera Hospital by Dr. Ayres' 
method; two grains of calomel with one or two drops of laudanum, every ten 
minutes. In eleven of these, there was not the slightest attempt at reaction, 
and only one case actually recovered ; two others survived the cholera, but one 
died of pneumonia, and the other from peritonitis. 



ANESTHETIC AGENTS. 

61. Death hy Chloroform. — At the meeting of the 16th of October last, a let- 
ter from Dr. Confevron, of Langres, brought before the Academy of Medicine 
of Paris a most appalling case of sudden death during the inhalation of chlo- 
roform. Madame Labrune, thirty-three years of age, a mother of a family, in 
robust health, and of a nervous and excitable temperament, had been subjected 
to anaesthesia by Dr. Confevron, a twelvemonth ago, for trifling surgical ope- 
rations. On the 23d of August last, this lady requested her dentist to remove 
a large molar tooth, and as she was apprehensive of the pain, she would not 
consent to the extraction, except she were placed under the influence of chlo- 
roform. As the dentist was not accustomed to this agent, I (says Dr. Confev- 
ron) was solicited, both by himself and the patient, to administer it. " Though 
I felt unwilling to use anaesthesia for operations of little importance, especially 
since the painful accidents which had occurred in very clever hands were made 
public, I thought myself justified in deviating from the rule I had laid down 
these eighteen months, and I conceived that the previous successful adminis- 
tration of chloroform to the patient was a guarantee of the safety of a second 
trial. I had, besides, made up my mind to produce a very slight numbness, 
since the operation was not important, and the po.in very short. I placed, there- 
fore, on a handkerchief a small pledget of cotton wool, of the size of a nut, 
and moistened it with less than fifteen minims of chloroform. Madame Labrune 
held it herself to her nostrils, and breathed it at a little distance, so that the 
surrounding air might freely mix with the anaesthetic vapours. In eight or 



1850.] Andesthetic Agents. 259 

ten seconds, the effect became apparent, by the blinking of the e3^elids. I then 
made a sign to the dentist that he might proceed to operate ; but the patient, 
who had had experience in angesthesia, not thinking herself sufficiently insen- 
sible, pushed away the hand of the operator, and making us understand 
by signs that insensibility was not complete, she brought the handkerchief 
nearer to her face, and made rapidly four or five more powerful inspirations. 
At that moment,' I removed the handkerchief myself from her face, and lost 
sight of her but just to put it on a table, and when I glanced at her again the 
face was already pale, the lips discoloured, the features shrunk, the eyes sunken, 
the pupils horribly dilated, the jaws contracted so as to prevent the dental ope- 
ration, and the head thrown backwards. The pulse was quite gone, the limbs 
were in a state of complete resolution, and a few inspirations at long intervals 
were the only signs of life which the patient gave us. Without losing a moment, 
everything which can be done in such a case was immediately had recourse to 
for two hours, but without success. Stimulation of the nostrils with ammonia, 
movements of the arms and thorax, repeated insufiiations of air into the chest, 
which was made to move artificially for some time ; frictions with ammonia 
over the thorax, and then all over the body ; cauterization of the prgecordial 
region with burning coals, and finally a galvanic current by means of a power- 
ful voltaic pile, which was just being used in the neighbourhood, and which 
was promptly placed at our disposal, were successively used, but nothing could 
avert a fatal termination, in the reality of which I could hardly believe. Since 
February, 1847, I have been using ansssthetic agents daily, both in private 
practice and in our hospitals, and never have I given smaller doses, nor acted 
with more caution than in this case. The chloroform had been inhaled, freely 
mixed with atmospheric air, without any apparatus, and nothing indeed was 
wanting to render the operation perfectly harmless. I was, moreover, aware 
that my patient was labouring under no organic disease which might counter- 
indicate chloroform. I should, however, mention, in order not to omit any 
circumstance, that Madame Labrune had been much disturbed during the day, 
and that I was ignorant of that fact when the operation was attempted; but 
this could hardly explain such a fearfully sudden accident. Permission to exa- 
mine the body was given by the family, and thirty-eight hours after death the 
necropsy was performed by myself, assisted by my colleagues, Messrs. Montrol 
and Faure. 

" The membranes of the brain, and especially the veins at the base of the 
skull, were gorged with black blood, and the sinuses of the dura mater were 
filled with this fluid. The cerebral substance, on being incised, presented san- 
guineous dots, and the capillaries, divided by the knife, allowed the oozing of 
very dark blood. The cerebral matter was intact, and of the normal consist- 
ence ; there was a rather large effusion of serum on the base of the cranium, 
which likewise filled the vertebral canal. In all the veins of the base of the 
skull, even in those of a very small calibre, we found a notable quantity of air 
bubbles intercepting the fluid, and easily displaced. The heart was soft, and 
an incision into the left auricle caused the evacuation of black blood, along 
with air-bubbles. There were no clots in the cardiac cavities. In the larger 
veins of the trunk, a great quantity of black and fluid blood was likewise found. 
The lungs crepitated well through their whole extent, and were of a slate-colour 
both externally and internally. The abdomen was distended with gas ; the in- 
testines were not opened. 

" The most striking and incomprehensible circumstance of this sad event is, 
that the patient, far from indicating, by a complaint or otherwise, that she was 
being suffocated, as did the lady in the Boulogne case, was able to point out 
that anaesthesia was not complete ; and four or five inspirations, made with a 
sort of pleasure, sufficed to bring on the highest degree of insensibility. It is 
evident that, in the present state of our knowledge, we have no means of fore- 
stalling such suddenly fatal cases, and I quite agree Avith Dr. Gorre (of Bou- 
logne), in thinking that it is highly imprudent to use chloroform, as is too often 
done, for trifling operations." — Lancet, Nov. 17th, 1849. 



260 ' Progress of the Medical Sciences. [Jan. 



MEDICAL JURISPRUDENCE AND TOXICOLOGY. 

62. On the Medico-Legal Appreciation of Ether and Chloroform. — M. Bay- 
ard protests against the employment of these substances for the detection 
of simulated diseases, or, rather, against the soundness of some of the con- 
clusions arrived at by those who have so employed them! Thus, for ex- 
ample, because certain contractions or rigidity of limbs have disappeared 
during its employment, these have been set doM^n as feigned, while every prac- 
titioner knows that a deformity produced by a dislocation, accompanied with 
violent muscular contraction, may cease on this becoming relaxed. Two cases 
which have fallen under the author's notice, incidentally illustrate the point. 
In the one, a man, suffering from diastasis, with swelling and chronic retrac- 
tion of the right foot, was etherized during the removal of a strumous tumour, 
and then complete resolution and mobility of the foot were produced. A young 
girl, agt. 17, was, while suffering from white swelling of the knee, etherized, in 
order that an operation for hare-lip might be performed ; and, during the inhala- 
tion, flexion and extension of the limb became quite easy to produce, these 
ceasing with the cessation of the etherization. 

But, supposing this dijScnlty not in the way, M. Bayard denies that the prac- 
titioner has a moral right, even for the detection of any simulated disease, to 
induce the " ethereal drunkenness,'' and continue it until the individual makes 
the necessary revelations. It would be an abuse of his position, on the part of 
any medical man, if, in proposing this means of verification, he did not apprise 
the suspected individual of the consequences of inhalation. Any declaration 
obtained from an accused person, to be valid, should be made voluntarily and 
with full consciousness. The extracting replies by the means of the induction of 
drunkenness or narcotism would be just as justifiable as by etherization; and 
to proceed in any such way is certainly not to revive the torture, but the con- 
sequences of the ordinary and extraordinary question. By the production of pain 
in former times, avowals were wrung from the innocent as well as from the 
guilty ; and have we any guarantee of the veracity of statements made under 
etherization? The following are M. Bayard's conclusions : — 

1. Etherization, which has been proposed for the detection of the simulation 
of certain diseases, by inducing an intoxication that renders the maintenance of 
a fixed idea of simulation impossible, and which induces actions or replies capa- 
ble of revealing such simulation, should never be employed but with the consent 
of the suspected person, previously informed of the consequences he is exposing 
himself to. 2. The administration of ether or chloroform should be compared to 
that of narcotics or spirituous liquors, which have never been employed by phy- 
sicians to induce involuntary revelations. 3. Even if the individual suspected 
consents to submit to etherization, this should not shield the medical man from 
any responsibility that may accrue from its toxical effects. 4. In the present 
state of science, we cannot say that simulated muscular contractions can always 
thus be detected. 5. If, in some cases, individuals submitted to etherization 
have been able to render an exact account of all that has happened around 
them, frequently other individuals have had dreams, hallucinations, and illu- 
sions, which they relate with all the conviction due to real fapts. Declarations 
of this kind can be received in a court of justice only with the most wary cir- 
cumspection. — Annales d' Hygiene, torn. xlii. pp. 165-201. 

[Seeing the occasional fatal results which follow upon the use of chloroform, 
the uncertainty of the revelations obtained by its aid, and the unsoundness of 
the principle upon which the experiment is based, we entirely agree Avith M. 
Bayard that this substance should not be employed for the detection of simu- 
lated disease. We have often thought that, in some of the procedures of army 
and naval surgeons, instituted for the same purpose, neither the dignity of the 
profession, the indications of science, nor the rights of humanity, have been 
su£&ciently consulted.] — Brit, and For, Med.-Chirurg. Rev., Oct. 1849. 



1850.] 261 



AMERICAN INTELLIGENCE. 



ORiaiNAL COMMUNICATION. 

Remarks upon the Presence of some Infusoria in the Tissues and jSecretions 
of Patients dying of Cholera. By W. I. Burnett, M. D. 

In the Am. Journ. of Med. JSci. for July, 1849, may be found an abstract 
of a paper of mine, upon the presence of certain vihriones in the secretions 
and tissues of patients dying of cholera. 

These observations were made upon some of the first cases of that disease, 
at its appearance early last summer. 

Although these observations were quite limited, it was then thought best 
to publish immediately the results, as it might serve to direct the attention of 
observers to this interesting subject. 

The facts, therefore, were alone stated, without any pre-judgment of theo- 
ries. 

Since that time, and during the past summer, when the cholera raged so 
severely in this city, I have had ample opportunities for the pursuance of this 
subject, in a manner to allow me to speak of it in a general way. 

It may be proper to allude first to the cavil of some who have supposed 
that the whole was an optical illusion, and that the particles in question are 
only the Brownian molecules in active motion. 

This objection belongs only to those who are unacquainted with observa- 
tions of this kind; and, although the Brownian motion pervades nearly every 
field of view, yet the adept becomes so accustomed to it, that it can scarce 
ever be mistaken for that irregular, and apparently voluntary motion belong- 
ing to the minute infusoria, and serving as the chief feature of their animal 
nature. 

The relations of these infusoria to this disease have many points of interest 
to be considered. 

In almost any rice-water dejection, or the urine of a cholera patient, there 
may be found millions of these vibriones (^Vibrio proUfer, Ehren.), in active 
motion; also they are occasionally present in some of the tissues, and espe- 
cially the muscular, a few hours after the death of the patient; but this 
last is very far from being common; and I remember to have seen them in 
these localities in two cases only. 

The whole result of my observations upon nearly forty subjects is, that 
these infusoria are nearly always present in the dejections and urine of these 
patients, and but rarely so, at least as fiir as could be seen, in the solid 
tissues. 

Now, the fact of the presence of vibriones (the same species), upon the in- 
crustations of teeth, and in diarrhoeal dejections from the alimentary canal, has 
for some time been known to microscopists; and some observations of my 
own in this direction, during the past summer and autumn, have convinced me 
that their presence is so common in these situations that it is rare to find an 
individual in whom they cannot be found; and not only is this species found, 
but other genera, and especially have I seen a species of the genus Spirillum, 
as quite common, not to mention the representatives of other dissimilar 
genera, which occasionally, though rarely, pass over the field of observation. 



262 American Intelligence. [Jan. 

All these are merely the inhabitants of the decomposing animal and vegetable 
matters in which they are found; and, as far as we can learn, occupy a no 
nearer relation to the system than as being tenants of effete matter, of which 
the latter is accidentally the depository. 

To those acquainted with these facts, the discovery of these infusoria in 
the tissues and dejections of cholera patients cannot be received with much 
novelty, or as a result which could not justly have been expected. 

Some observations of my own, instituted for the purpose, have shown to 
me that their presence is perhaps as frequently met with in the diarrhoeal 
dejections and tissues of patients dying of